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THE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA 

LOS  ANGELES 


U    4-      ■i.*?i'>"i.''.''.3l»'ji' 


Nervous  and  Mental  Disease  Monograph  Scries  No, 


Uv- 


Outlines  of  Psychiatry 


WM.  A.  WHITE,  M.D. 


,-,   --^M' 


Nf:V\     YORK 


ANNOUNCEMENT 


^—^  HE  Nervous  and  Mental  Disease 
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Nervous  and  Mental  Disease  Monograph  Serie 


Editors 

SMITH    ELY   JELLIFFE,  M.D. 
WM.  A.  WHITE,  M.D. 


No.  I.  Outlines  of  Psychiatry    .     . 

By  WM.  A,  \      .  M  D. 


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By  Drs.  GIERLICH  AND  FRIEDMAN 

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Price,  $1.00 


No.  3.  Isben,  the  Apost!e  of  the  Psychopath  .     . 

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(In  preparation) 


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Address  all  Commanications  to  JOURNAL  OF  NERVOUS  AND  MENTaf. 
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OUTLINES 


OF 


PSYCH  lATRY 


BY 

WILLIAM   A.  WHITE,  M.D. 

SUPERINTENDENT   GOVERNMENT    HOSPITAL    FOR   THE    INSANE,   WASHINGTON,  D.  C;     PROFESSOR    OF 
NERVOUS  AND  MENTAL  DISEASES,  GEORGETOWN  UNIVERSITY,  WASHINGTON,  D.  C;    PROFESSOR 
OF   MENTAL   DISEASES,    GEORGE  WASHINGTON  UNIVERSITY,  WASHINGTON,  D.  C,  AND 
LECTURER   ON   INSANITY,  U.  S.  ARMY  AND    U.  S.  NAVY    MEDICAL   SCHOOLS 


NEW   YORK 

THE   JOURNAL   OF   NERVOUS   AND   MENTAL    DISEASE 
PUBLISHING   COMPANY 

1907 


Copyright,  1907 
By  WILLIAM   A    WHITE 


i 


Press  of 

The  New  Era  Prjnting  COMPAlir 

Lancaster.  Pa. 


100 

FOREWORD 


In  putting  forth  this  Httle  work  it  is  not  expected  that  it 
will  take  the  place  of  the  larger  text-books.  No  claim  what- 
ever is  made  for  exhaustiveness,  completeness  or  originality 
— it  is  merely  intended  to  afford  a  helpful  guide  to  my  stu- 
dents, so  that  they  can  follow  my  lectures  more  easily  and  more 
satisfactorily.  I  have  endeavored  to  describe  in  a  manner  as 
clearly  as  possible  and  in  a  way  to  be  easily  understood  by  the 
students  the  principal  types  of  mental  disorder,  especially  with 
a  view  of  providing  the  young  physician  just  entering  on 
practice  with  a  working  knowledge  of  the  subject.  To  these 
descriptions  I  have  prefaced  a  short  account  of  the  nature  of 
the  human  mind  and  the  fundamental  psychological  processes 
for  the  purpose  of  providing  a  proper  foundation  for  what 
follows  and  also  to  place  the  student  in  possession  of  certain 
general  facts  so  that  he  will  be  better  able  to  orient  what  he 
may  observe. 

In  arranging  the  work  the  first  consideration  has  been  the 
convenience  of  the  student.  Important  words  are  italicized 
and  these  words  occurring  in  the  index  can  thus  be  readily 
found  by  reference  to  the  page,  while  the  student  will  find  it 
easier  to  skim  over  the  pages  rapidly  and  pick  out  just  what 
he  wants.  While  current  literature  on  insanity  has  been  freely 
consulted,  references  and  foot-notes  have  been  avoided  so  as 
not  to  detract  in  any  way  from  the  continuity  of  the  text,  and 
the  incorporation  of  extended  case  histories  has  also  been 
avoided  for  the  same  reason. 

I  wish  here  to  acknowledge  my  indebtedness  to  Dr.  Shep- 
herd Ivory  Franz  for  the  preparation  of  the  substance  of 
Chapter  VII,  and  to  Dr.  Smith  Ely  Jelliffe  for  many  valuable 


Kf 


70{l52^ 


IV  OUTLINES   OF   PSYCHIATRY. 

suggestions,  while  I  desire  also  to  record  my  thanks  to  the 
several  members  of  the  medical  staff  for  assistance  in  supply- 
ing case  histories,  stenograms,  and  in  many  other  ways. 

W.  A.  W. 

Go\t:rnment  Hospital  for  the  Insane, 
Washington,  D.  C, 
June  15,  1907. 


CONTENTS. 

PAGE. 

Foreword  iii 

Chapter  I.     Psychological  Introduction  i 

II.     Definition  of  Insanity 8 

III.  Classification  of  Mental  Disorders i6 

IV.  Causes  of  Mental  Disorders 21 

V.     Treatment  29 

VI.     General  Symptomology 34 

VII.     Examination  of  the  Insane 65 

VIII.     Paranoia  and  Paranoid  States 94 

IX.     Manic-Depressive  Psychoses 108 

X.     Paresis   124 

XI.     Dementia  Precox 142 

XII.     Involution   Melancholia 163 

XIII.  The  Senile  Psychoses 171 

XIV.  The  Infection-Exhaustion  Psychoses....   181 
XV.    The  Toxic  Psychoses 187 

XVI.  Psychoses  Associated  with  other  Diseases  205 

XVII.     Borderland  and  Episodic  States 216 

XVIII.     Idiocy  and  Imbecility 222 


OUTLINES  OF  PSYCHIATRY 


CHAPTER   I. 

PSYCHOLOGICAL   INTRODUCTION. 

Insanity  has  been  defined  as  an  absence  of  sanity.  This 
is  rather  an  evasion  than  a  definition.  The  difficulty  is  simply 
once  removed  and  it  becomes  necessary  to  define  sanity.  An 
attempt  to  do  this  would  demonstrate  much  the  same  difficul- 
ties that  we  had  when  attempting  to  define  insanity.  How- 
ever, a  material  advance  towards  both  ends,  or  at  least  towards 
understanding  both  conditions  can,  I  think,  be  made  by  describ- 
ing briefly  the  fundamental  processes  of  the  normal  mind. 
Before  doing  this,  however,  a  few  preliminary  considerations 
are  necessary. 

The  body  is  made  up  of  a  great  number  of  organs  each  one 
of  which  has  a  definite  purpose :  The  kidney  to  secrete  urine, 
the  lungs  to  carry  on  respiration,  the  heart  to  force  blood 
through  the  vessels,  the  stomach  and  intestines  to  digest  and 
absorb  nutrient.  Definite  as  is  the  function  of  each  of  these 
organs  its  action  must  be  timed  in  response  to  certain  condi- 
tions and  in  relation  to  the  other  organs  of  the  body  or  it  does 
not  serve  its  purpose  in  the  individual  economy.  The  stomach 
must  secrete  its  juices  when  food  is  introduced,  the  bladder 
contract  when  there  is  urine  to  be  expelled,  the  active  brain 
must  be  supplied  with  an  increased  amount  of  blood,  the  kid- 
neys and  the  skin  must  act  harmoniously  together  to  excrete 
certain  substances,  the  respirations  increase  on  physical  exer- 
tion and  so  on  indefinitely.  Now  it  is  the  duty  of  the  nervous 
system  to  see  that  the  functions  of  the  several  organs  are 

2  I 


2  OUTLINES    OF    PSYCHIATRY. 

rightly  timed  and  properly  adjusted  in  relation  to  one  another. 
This  is  the  function  of  the  lower  nerve  centers. 

The  highest  nerve  centers  of  the  cerebral  cortex  that  con- 
stitute the  physical  basis  of  mind  have  quite  a  different  func- 
tion. Their  duty  is  to  so  regulate  and  control  the  actions  of 
the  individual  as  to  best  serve  his  interests  in  his  relations  with 
his  environment. 

In  order  to  do  this  the  mind  must  obtain  knowledge  of  the 
environment  through  the  sense  organs,  assimilate  this  knowl- 
edge, and  then  act  in  accordance  with  it.  To  illustrate:  A 
man  standing  in  the  middle  of  the  street  sees  a  runaway  team 
dashing  towards  him.  His  sense  organs  take  the  information 
to  his  mind  of  the  presence  of  the  runaway  team,  its  distance 
from  him,  the  distance  to  the  sidewalk  from  where  he  stands 
and  many  other  things.  His  mind  assimilates  all  these  facts 
and  by  a  process  of  reasoning  reaches  the  conclusion  that  safety 
lies  in  his  immediately  gaining  the  sidewalk  which  is  in  front 
of  him.  The  necessary  volitional  processes  are  initiated  and 
thus  the  actions  of  the  individual  are  so  related  to  the  condi- 
tions in  his  environment  as  to  conserve  his  best  interests :  in 
this  case  to  save  his  life. 

In  order  that  the  adjustment  of  the  individual  to  his  envir- 
onment could  take  place  three  things  were  necessary :  ( i )  A 
knowledge  of  the  environment  must  be  gained.  (2)  This 
knowledge  must  be  associated  and  brought  into  relation  with 
previous  experiences.  (3)  It  must  be  transformed  into  the 
appropriate  actions.  The  sensorium  subserves  the  first  of 
these  functions,  the  intellect  the  second,  and  the  motorium  the 
third.  The  function  of  the  sensorium  is  perception,  of  the 
intellect  thinking,  and  of  the  motorium  volition.      (See  Fig.  i.) 

With  this  broad  view  of  the  function  of  consciousness  to 
guide  us  we  may  now  describe  the  separate  processes  more 
in  detail. 

As  we  have  seen  all  our  information  of  the  environment 
must  come  through  our  sense  organs  it  follows  of  necessity 
that  sensations  play  an  important  part  in  making  up  the  con- 


PSYCHOLOGICAL   INTRODUCTION.  3 

tent  of  consciousness.     These  sensations  are  the  result  of  the  i^ 
stimulation  of  the  sensory  nerves,  usually  their  terminals  in 
the  specialized  end  organs,  and  in  the  last  analysis  comprise 
the  unanalyzable  material  out  of  which  consciousness  is  com- 
posed much  as  the  atom  in  the  Daltonic  conception  of  matter 


SENSORIUM 

PERCEPTION 


INTELLECT 
THINKING 


MOTORIUM 
VOLITION 


Fig.  I.  a,  a^,  o^  a',  o",  represents  the  afferent  peripheral  nervous  sys- 
tem, the  avenues  for  conveying  sensory  impulses  inward  to  the  mind. 
z,  ^,  ^,  ^,  z*,  represent  the  efferent  peripheral  nervous  system,  the  ave- 
nues through  which  motor  responses  travel. 


was  supposed  to  be  the  unanalyzable  unit  which  by  combina- 
tion with  others  both  similar  and  dissimilar  went  to  form 
masses  of  matter  as  we  know  them.  So  the  eye  gives  us  sen- 
sations of  light  of  different  colors  and  intensities,  the  ear  sensa- 
tions of  sound  of  varying  qualities  and  loudness  and  so  on  in 
each  sensory  realm  the  sensations  received  being  variable  both 
qualitatively  and  quantitatively. 

If  we  will  stop  and  consider  for  a  moment,  however,  we  will 
see  at  once  that  these  elemental  sense  experiences,  like  atoms, 
cannot  exist  alone  and  uncombined :  That  sensations  of  light, 
sound,  pain,  coldness,  can  never  as  such  go  to  make  up  a  con- 
scious state.  In  front  of  me  as  I  write  is  something  which 
produces  the  sensation  of  a  variously  shaded,  round  patch  of 
yellow,  but  even  while  looking  at  it  I  know  much  more  of  it 


4  OUTLINES    OF    PSYCHIATRY. 

than  simply  that  it  is  a  patch  of  yellow :  I  recognize  it  as  an 
orange.  What  has  been  added  to  the  visual  sensations  of 
roundness  and  yellowness  to  produce  this  result?  Just  this. 
Many  times  in  the  past  have  I  had  the  same  sort  of  sensations 
of  roundness  and  yellowness  impressed  on  my  consciousness 
and  many  times  in  connection  with  these  sensations  have  been 
others  of  touch,  taste,  and  smell  and  to  their  combination  I 
have  in  the  past  given  the  name  orange.  So  now  when  the 
sensations  of  roundness  and  yellowness  are  received  they  call 
up  in  consciousness  those  other  sensory  elements  of  touch, 
taste,  and  smell  which  have  occurred  before.  The  association 
of  the  previous  with  the  present  sensory  elements  causes  me  to 
recognize  the  round  patch  of  yellow — not  solely  as  a  patch 
of  yellow — but  as  an  orange.  To  this  process  of  forming  an 
image  in  the  mind  of  an  object  presented  to  the  senses  is  given 
the  name  perception. 

It  is  this  process  of  perception  which  furnishes  to  the  indi- 
vidual the  knowledge  of  his  environment  which  by  association 
with  the  knowledge  gained  in  the  past  leads  to  appropriate 
actions.  This  process  of  association  is  an  association  with 
ideas  which  may  be  said  to  be  images  of  objects  formed  in  the 
mind  but  not  presented  to  the  senses  at  the  time.  The  only 
difference  then  between  percepts  and  ideas  is  the  presence  in 
the  former  of  sensory  elements. 

This  process  of  the  relation  of  percept  to  ideas  and  the 
association  of  ideas  one  with  another  or  in  general  terms  this 
process  of  the  assimilation  and  rearrangement  of  the  materials 
of  knowledge  furnished  by  the  senses  with  the  materials  already 
present  in  consciousness  is  the  process  oi  thinking.  Now  when 
from  the  association  of  two  or  more  ideas  there  issues  forth  a 
new  and  different  idea  the  process  which  produces  this  result 
is  the  process  of  reasoning  and  the  new  idea  is  known  as  a 
judgment. 

Having  received  information  of  the  environment  by  the 
process  of  perception  and  having  assimilated  the  various  per- 
cepts, reasoned  regarding  them  and  reached  certain  judgments, 


PSYCHOLOGICAL   INTRODUCTION.  5 

the  next  thing  in  the  order  of  events  is  the  initiating  of  appro- 
priate actions.  If  the  reasoning  is  at  all  complicated  there  are 
usually  several  judgments  formed,  each  one  of  which  may 
tend  to  express  itself  in  an  appropriate  action,  the  strongest 
one  finally,  however,  succeeding  in  expressing  itself.  This 
conflict  of  tendencies  has  been  described  as  the  "  battle  of 
motives  "  by  Ziehen  who  gives  the  following  illustration : 

"  I  see  a  rose  in  a  strange  garden  (stimulus  and  sensation). 
A  long  series  of  ideas  is  aroused  by  the  stimulus  and  the  visual 
sensation  of  the  flower  (idea-association).  For  instance,  the 
memory  of  the  rose's  fragrance  comes  to  mind,  then  I  think 
how  well  it  would  look  in  my  room,  that  it  is  the  property  of 
another,  that  plucking  it  would  be  punishable,  and  so  on. 
Only  after  the  whole  series  of  presentations  has  passed  before 
the  mind  does  action  follow,  and  whether  I  pluck  the  flower 
or  go  my  way  without  it  will  depend  upon  the  strength  and 
intensity  of  the  conquering  idea." 

The  conscious  realization  in  action  of  the  strongest  motive 
is  the  process  of  volition  and  is  accomplished  by  a  feeling  of 
freedom  to  choose  which  motive  shall  dominate.  The  sum 
total  of  the  actions  of  the  individual  is  known  as  conduct. 

All  of  these  various  processes  which  have  been  described 
must  of  course  be  conceived  of  as  taking  place  in  conjunction 
with  certain  physiological  processes  in  the  cells  and  fibers  of 
the  highest  nerve  centers.  These  physiological  processes, 
here  as  elsewhere,  involve  changes  in  the  energy  and  the 
material  substance  of  cells  and  fibers  and  so  when  a  certain 
mental  process  has  occurred  once  accompanied  by  its  correla- 
tive physiological  process  the  changes  in  nerve  cells  and  fibers 
will  have  left  such  an  impress  that  a  subsequent  process  of  this 
sort  will  occur  more  readily.  In  other  words  a  mental  process 
having  once  occurred  tends  to  recur  in  the  same  way  when  the 
same  conditions  are  repeated.  This  tendency  is  the  physiolog- 
ical basis  of  memory,  which  psychologically  may  be  said  to 
be  the  recurrence  to  consciousness  of  a  previous  experience 
and  the  recognition  of  it  as  having  occurred  before. 


O  OUTLINES    OF    PSYCHIATRY. 

All  mental  processes,  besides  these  special  qualities  which 
characterize  them,  are  accompanied  by  certain  general  condi- 
tions of  consciousness  known  as  affects  which  are  pleasant  or 
unpleasant,  pleasurable  or  painful,  agreeable  or  disagreeable, 
and  like  sensations  are  unanalyzable,  elemental,  constituents 
of  consciousness.  These  pleasurable  or  painful  conscious  states 
arise  as  the  result  of  the  interaction  between  the  individual 
and  the  environment  and  are  known  as  feelings  when  this 
interaction  is  relatively  simple  and  direct,  i.  e.,  a  shrill  whistle 
may  be  accompanied  by  a  feeling  that  is  disagreeable  to  the 
point  of  being  actually  painful.  When  the  interaction  is  rela- 
tively more  complex  and  indirect  there  may  result  the  state  of 
consciousness  known  as  an  emotion,  i.  e.,  the  bell  of  a  loco- 
motive and  the  hiss  of  an  air  brake  is  heard  coupled  with 
screams  and  cries  of  pain.  The  mind  at  once  pictures  to  itself 
an  accident  and  the  emotion  of  fear  arises  in  consciousness. 
If  the  interaction  is  still  more  complex  and  indirect  sentiments 
arise  such  as  honor,  patriotism,  etc. 

From  this  description  of  the  processes  of  the  mind  it  will 
be  seen  that  they  are  most  intimately  connected,  in  fact  that 
they  are  not  separate  and  distinct  in  any  sense,  but  only  parts 
of  a  large  whole.  The  old  psycholog}'  conceived  of  mind  as 
composed  of  a  number  of  cubby  holes  in  each  one  of  which  was 
pigeon-holed  a  special  faculty,  feeling,  thinking,  volition,  each 
one  of  which  was  quite  as  distinct  from  the  others  as  this  illus- 
tration implies.  Now,  however,  all  that  is  changed.  The  "  faculty 
concepts  "  are  conceived  of  as  what  they  really  are,  "  class  des- 
ignations of  certain  departments  of  the  inner  experience,"  and 
not  "  forces,  by  whose  means  the  various  phenomena  are  pro- 
duced." "  Objectively,  we  can  regard  the  individual  mental 
processes  only  as  inseparable  elements  of  interconnected 
wholes."  Mental  processes,  from  their  incidence  in  sensations 
to  the  release  of  the  motor  responses  constituting  conduct  are 
conceived  to  have  as  their  physical  substratum  a  continuous 
neural  process.  The  process,  although  differently  named  in 
different  parts  of  its  course  for  convenience  of  designation,  is 
a  continuous  one. 


CHAPTER   II. 

DEFINITION   OF   INSANITY. 

In  discussing  a  subject,  especially  if  there  be  some  ques- 
tion as  to  its  nature,  it  is  natural  that  the  first  consideration 
should  be  given  to  defining  it,  A  definition,  to  be  a  perfect 
one,  should  include  everything  that  the  term  defined  is  appli- 
cable to  and  exclude  everything  to  which  the  term  is  not 
applicable.  Innumerable  attempts  to  frame  a  definition  of  this 
sort  of  insanity  have  been  made  by  eminent  alienists  all  over 
the  world  but  up  to  the  present  time  it  can  not  be  said  that 
there  is  a  satisfactory  definition  of  insanity  in  existence.  And 
after  all  it  is  not  strange  that  this  should  be  the  state  of  affairs. 
Mind  is  a  function  of  the  highest  nerve  centers  of  the  brain, 
and  the  brain  is  the  most  complex  development  of  organic 
evolution.  It  does  not  seem  strange  therefore  that  the  dis- 
orders of  this  complex  should  not  be  reducible  to  the  simplicity 
of  a  definition. 

Notwithstanding  our  inability  to  define  insanity,  however,  it 
often  becomes  desirable  to  designate  what  insanity  is  as  accu- 
rately as  possible  in  a  few  words.  A  definition  is  not  infre- 
quently asked  for  in  court  and  it  is  necessary  for  the  physician 
to  have  one  ready  at  hand,  always,  however,  fully  appreciating 
its  limitations.  For  this  purpose  there  are  several  short  defini- 
tions which  are  good.     Some  of  the  best  are  the  following : 

That  mental  condition  characterized  by  a  prolonged  change 
in  the  usual  manner  of  thinking,  acting,  and  feeling,  the  result 
of  disease  or  mental  degeneration  (Chapin). 

Insanity  is  a  manifestation  in  language  or  conduct  of  disease 
or  defect  of  the  brain  (Peterson). 

A  cerebral  affection,  ordinarily  chronic,  without  fever,  char- 
acterized by  disorders  of  the  sensibility,  of  the  intelligence,  and 
of  the  will  (Esquirol). 

7 


8  OUTLINES    OF    PSYCHIATRY. 

Insanity  is  a  special  disease,  a  form  of  alienation  character- 
ized by  the  accidental,  unconscious,  and  more  or  less  permanent 
disturbance  of  the  reason  (Regis). 

Insanity  is  a  more  or  less  permanent  disease  or  derangement 
of  the  brain  producing  disordered  action  of  the  mind  in  such 
a  way  as  to  put  the  subject  in  a  condition  varying  from  his 
normal  self  and  out  of  relation  with  his  environment  (Brower 
and  Bannister). 

Insanity  is  a  serious  alteration  in  the  psychical  functions  of 
the  brain.  This  leads  to  such  departure  from  the  normal  in 
speech  and  conduct  that  the  patient  can  no  longer  adapt  him- 
self sufficiently  to  his  environment  (Dana). 

Insanity  is  a  symptom  of  perverted  function  or  of  disease  of 
the  brain  that  impairs  or  destroys  mental  integrity  (Eskridge). 

All  of  these  definitions  have  their  good  points  as  well  as  their 
defects.  Perhaps  by  combining  the  good  points  and  elimi- 
nating the  bad  we  could  hope  to  reach  a  definition  somewhat 
more,  although  of  course  not  altogether,  satisfactory. 

The  word  insanity  is  applied  with  reference  to  the  mind,  not 
with  reference  to  the  organ  affected  or  the  disturbance  in  that 
organ,  whatever  it  may  be.  The  word  is  used  to  denote  a  condi- 
tion of  the  function  mind  and  not  of  the  organ  brain.  We 
may  then  start  our  definition  by  saying  that  insanity  is  a  dis- 
order of  the  mind.  Mind,  however,  as  we  have  already  had 
reason  to  assume,  must  be  conceived  of  as  being  the  expression 
of  a  neural  process,  and  a  disorder  of  mind  cannot  be  conceived 
of  without  postulating  a  disturbance  in  this  neural  process.  If 
then,  for  the  purpose  of  this  definition,  we  use  the  word  disease 
to  indicate  such  a  disturbance  in  the  neural  process,  and  the 
word  brain  to  apply  to  the  physical  substratum  of  mind  then 
we  may  amplify  our  definition  by  adding  due  to  disease  of  the 
brain. 

The  use  of  the  word  disease  here  is,  I  am  aware,  somewhat 
broader  than  usual.  It  is,  however,  desirable  to  make  the 
wording  of  a  definition  simple,  avoiding  as  far  as  possible 
explanatory  or  abstruse  phrases.     Disease  ordinarily  refers  to 


DEFINITION    OF    INSANITY.  9 

a  process  producing  tissue  changes.  While  many  of  the  forms 
of  insanity  are  due  to  such  a  condition  in  the  brain  there  are 
others  that  present  no  demonstrable  lesion  or  in  fact  are  due 
to  disease  of  some  other  organ.  For  instance,  nephritis  may 
cause  uraemia,  which  in  time  may  produce  a  psychosis  due  to 
the  poisoning  of  the  brain  by  the  products  of  faulty  tissue 
metabolism.  Here  the  patient  would  hardly  be  thought  of  as 
suffering  from  a  disease  of  the  brain,  but  rather  from  a  disease 
of  the  kidneys.  The  insanity  is  entirely  a  secondary  affair. 
We  cannot  doubt,  however,  that  there  is  a  disturbance  of  the 
neural  processes  underlying  the  phenomena  of  mind.  Quite 
likely  these  disturbances  are  too  minute  to  result  in  demon- 
strable tissue  changes,  perhaps  they  may  be  chemical  in  nature, 
they  are  nevertheless  as  real  as  though  they  were  on  a  larger 
scale,  and  it  seems  to  me  that  such  alterations  can  properly 
come  under  the  connotation  of  the  word  disease.  Further 
than  this  the  conception  of  insanity  as  due  to  disease  of  the 
brain  is  entirely  in  harmony  with  modern  ideas  of  the  relation 
of  the  mind  to  the  brain  and  with  modern  brain  pathology 
which  is  constantly  narrowing  the  group  of  insanities  without 
demonstrable  changes  in  the  brain. 

To  be  more  specific.  Of  what  does  this  disorder  consist? 
It  must  consist  of  disorders  of  some  or  all  of  the  mental  proc- 
esses already  described.  The  fundamental  processes  of  mind 
disorder  of  which  produces  insanity  are  thinking,  feeling  and 
acting.  Disturbance  of  the  process  of  receiving  information 
from  the  environment  cannot  of  itself  constitute  insanity. 
Thus  blindness,  whether  peripheral  or  central  in  origin,  simply 
makes  it  impossible  for  the  individual  to  receive  certain  kinds 
of  sensory  experiences,  it  does  not  produce  a  disorder  of  the 
mind. 

The  elementary  materials  of  knowledge  are  brought  in  from 
the  sense  organs  by  the  afferent  nerv^es.  Disturbances  in  the 
sense  organs  and  nerves  leading  from  them  can  therefore  only 
result  in  a  change  in  the  character  of  this  material  brought  to 
the  mind  and  cannot  in  any  way  be  symptoms  of  its  disorder. 


lO  OUTLINES    OF    PSYCHIATRY. 

Simple  sensations,  however,  practically  never  occur  without 
some  element  of  perception  and  these  simple  perceptions  stand 
at  one  end  of  a  series,  the  other  end  of  which  is  constituted  of 
the  most  complex  intellectual  operations. 

Although  I  have  designated  perception  as  the  function  of 
the  sensorium  yet  this  does  not  strictly  conform  to  the  facts  in 
the  case  and  was  rendered  necessary  because  of  the  limitations 
of  language  in  an  attempt  to  classify  the  mental  processes  in  an 
easily  intelligible  way.  As  soon  as  one  attempts  to  split  things 
up  in  nature  into  distinct  and  clearly  defined  subdivisions  we 
must  compromise  somewhere,  because  such  clean-cut  divisions 
do  not  exist,  but  as  in  this  case  are  constructed  purely  for 
convenience. 

The  process  of  perception,  as  long  as  it  was  involved  solely 
in  associating  present  with  past  sensations,  might  be  said  to  be 
purely  a  function  of  the  sensorium,  but  as  was  said  above  pure, 
elementary  sensations  practically  never  occur,  so  that  percep- 
tion always  involves  association  with  previous  mental  states, 
feelings,  ideas,  and  when  as  a  result  the  round,  yellow  patch 
of  color  in  front  of  me  is  perceived  to  be  an  orange  such  com- 
plicated mental  processes  are  involved  as  recognition,  classi- 
fying, naming.  The  processes  are  all  processes  of  assimila- 
tion, combination,  and  rearrangement  of  the  materials  of 
knowledge,  and  as  such  are  functions  of  the  intellect.  It  is 
for  these  reasons  that  disorders  of  perception  are  not  included 
in  the  definition  of  insanity,  for  when  they  occur  they  involve 
disorders  of  thinking.  The  mind  must  be  disordered  before 
the  materials  of  knowledge  brought  in  from  the  sense  organs 
by  the  afferent  nerves  can  be  so  combined  as  to  produce  symp- 
toms of  insanity.  The  most  characteristic  disorders  of  per- 
ception, hallucinations,  probably  never  occur  primarily  as  evi- 
dence of  mental  disease,  but  only  secondarily  as  a  result  of 
disorder  of  the  central  receiving  apparatus. 

Disorders  of  memory  also  cannot  alone  constitute  insanity. 
These  disorders  are  in  the  main  disorders  of  impressibility  and 
of  retentiveness,  but  impressibility  and  retentiveness  in  reality 


DEFINITION    OF   INSANITY.  1 1 

are  conditions  of  the  physical  substratum  underlying  the  mani- 
festations of  memory.  The  mere  fact  that  this  nervous  sub- 
stratum is  impressed  more  or  less  deeply  and  permanently  by  a 
process  occurring  within  it  does  not  in  any  way  involve  the 
nature  of  the  special  process  under  consideration.  Thus  dis- 
order of  memory  alone,  unaccompanied  by  other  symptoms  of 
the  disorder  on  which  it  depends  or  by  secondary  symptoms 
growing  out  of  it,  quite  contrary  to  the  popular  belief,  cannot 
constitute  insanity,  although  it  is  frequently  found  as  an  inti- 
mate part  of  the  clinical  picture. 

Disturbances  in  the  processes  of  thinking,  feeling,  and  acting 
we  may  expect  to  find  in  every  case.  In  the  old  "pigeon 
hole  "  psychology  with  its  many  "  faculties  "  we  might  expect 
to  find  disorders  of  the  most  circumscribed  kind.  Now,  how- 
ever, we  conceive  the  neural  process  underlying  mind  to  be 
continuous.  Any  disturbance  which  produces  insanity  is  a  dis- 
turbance of  this  process,  and  the  process  as  a  whole  must  suffer 
from  a  disturbance  of  any  part  of  its  course.  Of  course  the 
amount  of  the  disturbance  may  be  variously  distributed  so  that 
the  brunt  may  fall  here  or  there,  but  feeling,  thinking  and 
acting  may  be  expected  all  to  show  some  trace  of  disorder  if 
examined  into  carefully,  although  it  may  appear  that  only  one 
is  affected.  For  instance,  paranoia  was  long  thought  to  show 
only  intellectual  and  perhaps  volitional  disturbance.  We  now 
know,  however,  that  disturbances  of  feeling  are  among  the 
most  prominent  of  its  early  symptoms. 

What  is  the  nature  of  this  disorder  of  thinking,  feeling,  and 
acting  which  constitutes  insanity?  The  use  of  the  word  in- 
sanity presupposes  the  existence  of  a  previous  state  of  sanity. 
Now  sanity  may  not  by  any  means  be  a  normal  condition. 
There  are  all  sorts  of  mental  states  of  idiocy,  idio-imbecility, 
imbecility,  and  feeble-mindedness  that  are  far  from  normal, 
but  they  are  conditions  which  for  the  individual  in  question  are 
sane.  In  drawing  a  distinction  between  dementia  and  idiocy, 
Esquirol  well  said:  "The  demented  man  is  deprived  of  the 
good  that  he  formerly  enjoyed;  he  is  a  rich  man  become  poor; 


12  OUTLINES    OF    PSYCHIATRY. 

the  idiot  has  ahvays  Hved  in  misfortune  and  poverty."  The 
idiot,  the  imbecile,  the  feeble-minded  lack  something;  the  in- 
sane are  suffering  from  a  disorder  of  that  which  they  possess. 
We  thus  may  find  all  sorts  of  mental  conditions  which  are  sane 
for  the  individual,  and  as  we  have  no  normal  standard  of  com- 
parison for  all  people,  the  best  we  can  do  is  to  compare  the 
individual  with  his  own  normal  standard,  with  his  condition 
previous  to  the  onset  of  disorder;  in  other  words,  with  the 
state  of  mind  that  has  been  normal,  habitual,  usual  with  him. 

Reviewing  all  the  conclusions  thus  far  reached  adds  to  our 
definition  so  that  it  reads  now :  Insanity  is  a  disorder  of  the 
mind  due  to  disease  of  the  brain  manifesting  itself  by  a  more 
or  less  prolonged  departure  from  the  individiiars  usual  manner 
of  thinking,  feeling,  and  acting. 

Having  indicated  thus  far,  in  a  general  way,  what  insanity 
is ;  what  it  is  due  to ;  what  the  processes  involved  are ;  and  the 
nature  of  their  involvement,  there  remains  but  one  further 
feature  that  I  believe  a  definition  of  insanity  should  contain. 

In  my  description  of  the  functions  of  the  brain  I  showed 
that  in  general  the  function  of  the  brain  is  to  subserve  the 
adjustment  of  the  individual  to  his  environment.  Of  course 
in  general  such  an  adjustment  constitutes  life  itself,  which  as 
defined  by  Spencer  is  "  the  continuous  adjustment  of  internal 
relations  to  external  relations."  But  whereas  the  lower  nerve 
centers  subserve  the  adjustment  of  the  various  organs  with 
one  another  and  with  external  conditions,  the  higher  centers, 
the  physical  substratum  of  mind,  subserve  the  adjustment  of 
the  individual  as  a  whole  to  external  conditions.  It  therefore 
J  follows  that  the  most  full  and  complete  mental  life  is  that 
which  adjusts  the  individual  most  completely  to  the  conditions 
of  his  environment :  the  best  mind,  that  which  is  capable  of 
the  greatest  latitude  of  adjustment,  that  enables  the  possessor 
to  fill  any  position  in  life  in  which  he  may  be  placed.  And 
conversely,  the  poor  mind,  the  narrow  mind,  permits  only  a 
limited  adjustment,  either  limited  in  the  particular  position  of 
life  occupied  by  the  individual  or  limited  as  to  its  possibilities 


DEFINITION    OF   INSANITY.  1 3 

of  scope,  or  both.  The  mental  life  is  carried  on  within  rela- 
tively narrow  limits. 

Whatever  may  be  the  limits  of  adjustability  for  the  indi- 
vidual any  disorder  of  the  mental  processes  must  necessarily 
interfere  with  it.  But  as  we  have  seen,  in  discussing  the 
nature  of  this  disorder  that  we  had  no  absolute  standard  of 
comparison  but  were  forced  to  compare  the  individual's  present 
condition  with  his  condition  in  the  past,  with  his  usual  condi- 
tion, so  here  all  degrees  of  adjustability  are  found  in  different 
people  and  the  most  limited  may,  for  the  individual  concerned, 
be  normal.  The  interference  with  the  adjustment  of  the  indi- 
vidual with  his  environment  is  therefore  a  disorder  in  so  far 
as  it  is  a  departure  from  his  previous,  his  usual  condition. 

From  the  standpoint  of  disordered  function,  insanity  is  then 
the  expression  on  the  part  of  the  individual  of  his  type  of  reac- 
tion to  the  conditions  of  his  environment.  Insanity  cannot  be 
spoken  of  as  a  disease  any  more  than  hyperchlorhydria ;  it  is 
but  a  symptom — a  type  of  reaction,  an  effort  on  the  part  of  the 
individual  to  meet  conditions.  It  is  true  that  some  disease  may 
be  at  the  bottom  of  this  disturbance  of  adjustment,  perhaps  a 
disease  of  the  brain  such  as  paresis  renders  the  reactions  of  the 
individual  inadequate,  for  we  must  remember  that  the  brain  is 
just  as  truly  a  part  of  the  environment  of  the  mind  as  the  rest 
of  the  body,  or  in  fact  as  anything  even  outside  of  the  body. 

The  complete  definition  of  insanity  would  then  read :  hisan- 
ity  is  a  disorder  of  the  mind  due  to  disease  of  the  brain  mani- 
festing itself  by  a  more  or  less  prolonged  departure  from  the 
individual's  usual  manner  of  thinking,  feeling,  and  acting,  and 
residting  in  a  lessened  capacity  for  adaptation  to  the  environ- 
ment. 

As  I  have  intimated  all  along  a  perfect  definition  of  insanity 
is  impossible  because  our  knowledge  of  the  subject  to  be  defined 
is  not  complete.  As  our  knowledge  increases  our  ideas  must 
constantly  change  and  definitions  can  be  but  the  crystallized 
product,  as  it  were,  of  our  ideas  at  any  one  time.  We  can  see 
already  how  far  we  have  advanced  from  the  time  of  Esquirol, 


14  OUTLINES    OF    PSYCHIATRY. 

who  emphasized  in  his  definition  that  insanity  was  a  cerebral 
affection  "  without  fever." 

Aside  from  these  considerations  we  found  that  the  definition 
had  to  be  at  best  a  compromise.  To  clearly  define  a  subject, 
to  put  a  fence  about  it,  as  it  were,  is  impossible,  when  as  a 
matter  of  fact  that  subject  merges  into  the  adjacent  territory 
at  all  points.  We  found,  for  instance,  that  there  was  no 
standard  of  comparison  that  could  be  called  sanity,  deviations 
from  which  constitute  insanity,  and  again,  even  in  the  use  of 
language  difficulties  arose  and  the  word  disease  had  to  be 
broadened  in  its  scope  of  application,  while  the  term  perception 
was  seen  to  stand  for  a  process  so  indefinite  in  its  limitations 
as  to  result  in  serious  embarrassment  in  its  use. 

The  definition  finally  reached  is,  I  fully  realize,  imperfect 
and  at  best  a  compromise,  and  I  am  aware  that  it  does  not 
greatly  differ,  especially,  in  parts,  from  the  definitions  already 
in  existence.  I  have  endeavored,  however,  to  make  the  word- 
ing of  it  somewhat  more  exact  and  its  synthesis,  I  trust,  may 
prove  a  suggestive  review  in  a  few  words  of  the  nature  of 
insanity  in  the  light  of  our  present  knowledge. 


CHAPTER   III. 
CLASSIFICATION   OF  MENTAL   DISORDERS. 

When  we  come  to  the  question  of  the  classification  of  the 
different  forms  of  insanity  we  find  a  condition  of  affairs  quite 
as  unsatisfactory  as  that  which  confronted  us  in  attempting  to 
define  it.  Almost  every  author  of  note  has  put  forth  his  own 
separate  classification  and  we  are  treated  to  all  kinds  from  the 
simplest  comprising  only  three  or  four  groups  to  the  most 
complex  comprising  forty  or  fifty  or  even  more.  The  problem 
of  classification  has  been  approached  from  every  side :  the  psy- 
chological, the  pathological,  the  etiological  and  the  clinical,  and 
while  some  authors  adhere  to  one  point  of  view  the  majority 
do  not,  but  offer  a  classification  based  on  all  four  considera- 
tions. This  latter  position  is  practically  necessary  as  there  are 
types  which  lend  themselves  only  to  classification  from  one  of 
these  standpoints  and  find  no  classification  on  any  other  basis. 

As  a  matter  of  fact  our  knowledge  of  insanity  is  altogether 
too  limited  at  present  to  justify  the  expectation  that  the  problem 
of  classification  can  be  solved.  Any  attempt  at  grouping 
mental  disorders  under  separate  heads  must  at  present  be  but 
tentative  and  incomplete.  The  author  will  not  attempt  to  offer 
any  scheme  of  classification  but  in  the  various  chapters  of  this 
work  will  discuss  the  forms  of  mental  disorder  which  are  gen- 
erally acknowledged  to  exist  and  while  endeavoring  to  give  a 
clear  picture  of  types  will  take  the  broad  view  which  realizes 
that  the  different  forms  of  mental  derangement  are  not  capable 
of  clean-cut  demarkations  but  that  on  the  contrary  many  of  the 
present  groups  will  in  the  course  of  time  be  broken  up  into 
smaller  groups  as  we  come  to  more  accurately  differentiate 
cases  and  appreciate  more  fully  the  true  value  of  signs  and 
symptoms.     In  fact,  we  are  only  beginning  to  learn  that  dis- 

15 


1 6  OUTLINES    OF    PSYCHIATRY. 

ease  types  are  not  the  absolutely  definite  things  they  were 
originally  supposed  to  be  and  that  each  and  every  case  need 
not  of  necessity  be  classified  under  one  and  only  one  caption 
for  all  time.  A  diagnosis  that  is  in  order  to-day  may  be  quite 
inaccurate  and  non-descriptive  six  months  hence,  while  aside 
from  the  fact  that  in  the  course  of  the  chronic  psychoses  acute 
symptoms  may  develop  which  have  absolutely  no  relation  to 
the  fundamental  disease  type  we  must  appreciate  the  fact  that 
there  are  many  cases  that  so  truly  partake  of  the  symptoms  of 
two  psychoses  as  to  make  their  relegation  to  either  group 
equally  impossible.  Then  again  within  the  larger  groups  all 
grades  of  transition  cases  may  be  found,  while  a  certain  few 
cases  defy  all  attempts  at  classification  whatever. 

The  term  insanity  includes  a  great  multitude  of  different  con- 
ditions— of  different  sorts  of  reactions — due  to  a  host  of  dif- 
ferent kinds  of  causes  and  the  explanation  of  the  difficulty, 
in  fact  the  impossibility  of  classifying  mental  disorders  on  any 
one  basis — the  etiological,  the  pathological,  the  psychological — 
is  at  once  apparent.  It  would  be  just  as  sensible  to  try  and 
force  under  one  head  all  the  diseases  that  might  involve  the 
kidney,  including  sarcoma  and  tuberculosis  with  the  nephritides 
proper. 

It  is  true  that  the  symptoms  of  mental  disorder  tend  to 
arrange  themselves  into  groups,  but  the  constancy  of  these 
groups  is  a  very  variable  factor,  and  like  the  epileptologist 
who  no  longer  speaks  of  epilepsy  as  a  concrete  entity  but  speaks 
rather  of  the  epilepsies,  so  we  are  getting  away  from  the  idea 
of  distinct,  definite  psychoses  and  are  using  such  terms  as  the 
dementia  paralytica  group,  the  manic-depressive  group,  the 
hysteria  group,  etc. 

These  groups,  the  so-called  clinical  types,  are  not  clean-cut 
entities  but  are  only  groups  of  symptoms  which  either  seem  to 
occur  more  frequently  in  combination  or  else  have  been  more 
definitely  and  clearly  seen  because  of  the  nature  of  that  combi- 
nation. In  fact  types  as  such  may  be  said  to  be  in  the  minor- 
ity.    The  great  mass  of  cases  seen  are  combinations  more  or 


CLASSIFICATION    OF    MENTAL   DISORDERS.  1/ 

less  intermediate  in  character.  The  conception  of  types  in 
order  to  be  accurate  must  be  from  a  broadly  biological  view- 
point. Types  are  like  species.  They  have  innumerable  transi- 
tion and  intermediate  forms.  It  is  as  if  overlooking  a  vast 
though  young  forest.  Here  and  there  are  certain  trees  which 
because  of  their  size  or  prominent  location  stand  out  distinct 
from  the  others.  These  would  at  once  be  picked  out  by  the 
observer  as  types,  yet  the  forest  as  a  whole  is  not  composed 
of  these  but  of  the  immense  number  of  smaller  trees  among 
which  these  few  stand  out  definitely,  and  a  more  detailed  study 
of  the  majority  of  the  trees  of  approximately  the  same  size 
would  reveal  minor  differences  of  structure;  for  example,  in 
the  form  of  leaf,  thickness  of  bark,  inclination  of  branches, 
color  of  flowers,  etc.,  many  of  which  might  only  serve  to  dis- 
tinguish the  individuals,  while  others  would  be  of  sufificient 
importance  to  constitute  varieties,  or  even  species. 

Insanity,  therefore,  is  not  a  disease;  it  is  rather  a  class  of 
disorders  which  tend  to  arrange  themselves  with  greater  or  less 
distinctness  into  groups  of  reaction  types.  Its  study  is  there- 
fore primarily  a  study  of  function  and  must  be  conducted  not 
in  the  autopsy  room  but  in  the  psychological  laboratory.  And 
this  study  of  disordered  function  will  only  reach  its  full  fruition 
when  the  results  of  the  detailed  analysis  of  abnormal  reaction 
types  are  correlated  with  the  results  of  a  study  of  the  mental 
"'  make-up "  of  the  individual  before  he  becomes  insane — in 
other  words,  a  psycho-analytical  study  of  character. 

Perhaps  this  is  best  illustrated  clinically  when  we  consider 
any  one  of  the  etiological  factors  of  insanity.  Take  for  ex- 
ample alcohol.  Now  there  are  a  number  of  psychoses  that 
seem  to  occur  almost  solely  under  the  influence  of  alcohol.  Of 
the  various  so-called  alcoholic  psychoses  one  patient  will  de- 
velop delirium  tremens,  another  acute  hallucinosis,  a  third 
Korsakoff's  psychosis.  What  conditions  the  special  form  of 
psychosis  in  each  case  we  do  not  know.  On  the  other  hand 
certain  patients  as  a  result  of  alcohol  develop  entirely  different 
psychoses,  the  alcohol  perhaps  conditioning  the  outbreak  of  an 
3 


i8 


OUTLINES    OF    PSYCHIATRY. 


attack  of  manic-depressive  insanity  leading  to  the  break  down 
of  dementia  precox  or  the  development  of  paresis. 

This  study  of  character  has,  fortunately,  begun  to  be  appre- 
ciated and  is  already  accumulating  a  considerable  literature 
and  leading  to  very  suggestive  results.  We  have  for  some 
time  known  very  well,  in  a  general  way,  the  unbalanced  char- 
acter, the  epileptic  character,  the  hysterical  character,  and  the 
unresistive  character  recognized  so  often  in  general  medicine 
because  of  the  abnormal  reaction  to  febrile  disturbances,  easily 
developing  delirium  as  a  result  of  only  a  moderate  fever,  and 
while  recent  studies  have  outlined  the  differences  in  character 
as  manifested  by  sex,  and  the  study  of  the  psychology  of  psy- 
chasthenia  has  given  us  an  understanding  of  the  psychasthenic 
character,  we  are  only  beginning  to  recognize  those  types  that 
may  later  develop  a  psychosis.  We  perhaps  have  definite  types 
of  character  which  tend  under  appropriate  conditions  to  de- 
velop the  manic-depressive  type  of  reaction  while  others  tend 
to  the  development  of  deterioration  types. 

The  individual  is  a  biological  unit  and  must  be  so  consid- 
ered in  relation  to  other  individuals,  to  society.  If  this  is 
forgotten  the  perspective  is  lost.  We  no  longer  consider  the 
end  and  aim  of  psychiatry  either  to  find  a  diseased  nerve  cell 
or  to  make  a  hard  and  fast  diagnosis  of  a  given  condition  at 
a  given  time.  If  we  are  to  understand  the  psychosis  we  must 
understand  the  individual,  we  must  study  not  only  his  origin 
and  development  but  his  adjustment  to  conditions.  We  can 
not  understand  a  psychosis  by  subjecting  it  to  cross-section  for 
the  purpose  of  defining  its  content  at  a  particular  point,  or  by 
subjecting  it  to  longitudinal  section  for  the  purpose  of  tracing 
the  beginning  and  the  end  of  symptoms.  Such  subjection  to 
the  narrow  field  of  an  optical  section  will  not  do — it  must  be 
studied  as  a  life  history.  Our  patients  must  be  considered  as 
individuals  who  under  certain  conditions  have  reacted  in  cer- 
tain ways.  The  type  of  reaction  can  only  reach  its  explanation 
in  the  type  of  person  displaying  it. 

Without  going  further  into  details  I  will  rest  by  giving  the 
classification  that  will  be  followed  in  this  work. 


CLASSIFICATION   OF   MENTAL   DISORDERS.  I9 

1.  Paranoia  and  Paranoid  States. 

2.  Manic-Depressive  Insanity. 

3.  Paresis. 

4.  Dementia  Precox. 

5.  Involution  Melancholia. 

6.  Senile  Psychoses. 

7.  Infection-exhaustion  Psychoses. 

8.  Toxic  Psychoses. 

9.  Psychoses  Associated  with  Other  Diseases. 

10.  Borderland  and  Episodic  States. 

11.  Idiocy  and  Imbecility. 


CHAPTER   IV. 

CAUSES  OF  MENTAL  DISORDERS. 

As  in  other  departments  of  medicine,  so  here  we  find  two 
classes  of  causes  operative — predisposing  and  exciting.  The 
predisposing  causes  are  made  up  of  those  conditions  existing 
within  the  individual  and  which  render  him  liable  to  the  devel- 
opment of  mental  disorder  under  favorable  circumstances.  The 
exciting  causes  are  those  circumstances  or  conditions  which 
produce  the  actual  attack  of  mental  disturbance  operating 
usually  upon  predisposed  soil.     The  predisposing  causes  may 


'  Individual. 


'  Predisposing. 


Causes 

of 
Insanity. 


General. 


'  Physical. 


Exciting 
(stress). 


.  Mental. 


Inherited  Predisposition 
(heredity). 

Acquired  Predisposition. 

Age. 

Physiological  Epochs. 

Sex. 

Civil  Condition. 

Climate. 

Civilization. 


Toxic. 

Traumatic. 
Infectious. 


Exogenous. 
Endogenous. 


Exhaustion. 
-Bodily  Disease. 

Acting  over  a  short  period  of 
time — such  as  Fright. 

Acting  over  a  long  period  of 
time — such  as  Worry. 


CAUSES   OF    MENTAL  DISORDERS.  21 

be  likened  to  a  train  of  gunpowder,  the  exciting  causes  to 
the  match  that  fires  it. 

The  predisposing  causes  are  from  their  nature  in  the  main 
inherited,  although  a  predisposition  to  mental  disease  may  be 
acquired,  i.  e.,  by  systematic  poisoning  (alcohol),  the  prolonged 
debihtation  of  disease  (tuberculosis),  etc.  The  exciting  causes 
can  all  be  classified  under  the  general  caption  of  stress,  mental 
or  physical,  and  comprise  the  various  factors  which  are  imme- 
diately causative  of  the  outbreak  of  the  attack.  Our  classifi- 
cation of  causes  would  then  be  the  following: 

Predisposing  Causes. 

Individual:  Inherited  Predisposition. — An  inherited  predis- 
position to  insanity  is  found  in  from  30  to  90  per  cent,  of  cases 
according  to  different  authorities,  while  the  average  for  all 
conditions  has  been  estimated  at  from  60  to  70  per  cent.  But 
any  one  who  is  at  all  familiar  with  the  collecting  of  statistics 
must  know  how  impossible  it  is  for  them  to  fully  represent  the 
facts  in  such  a  matter. 

If  we  will  take  up  any  annual  report  of  an  institution  for 
the  insane  and  turn  to  the  table  giving  the  causes  of  insanity  in 
the  several  patients  under  treatment,  we  will  find  assigned  such 
causes  as  these :  "  business  anxiety,"  "  death  of  mother,"  "  loss 
of  property,"  "  disappointment  in  love,"  "  domestic  troubles," 
"  excessive  study,"  "  political  excitement."  How  many  of  us 
but  have  suffered  at  some  time  or  other  from  some  or  perhaps 
all  of  these  so-called  causes  of  insanity?  Certainly  we  have 
all  had  business  worries ;  certainly  we  have  all  lost  property  at 
some  time,  otherwise  our  good  fortune  is  phenomenal;  cer- 
tainly we  have  all  been  subject  to  political  excitement  many 
times,  and  all  of  us  presumably  have  lost  a  dear  friend  or  rela- 
tive, perhaps  a  father  or  mother.  Dr.  Carlos  F.  McDonald 
says  very  forcibly  on  this  subject,  "...  that  substantially 
every  individual  at  some  time  or  other  during  his  life  is  ex- 
posed, in  many  cases  repeatedly,  to  many  of  the  so-called  excit- 
ing causes  of  insanity,  both   mental  and  physical,  and   yet, 


22  OUTLINES    OF    PSYCHIATRY. 

despite  this  fact,  we  find  that  sanity  is  the  rule — insanity  the 
exception." 

In  ascribing  these  causes  what  has  been  done  is  simply  this : 
The  particular  set  of  conditions  which  happened  to  maintain 
at  the  time  the  patient  was  attacked  with  insanity  have  been 
tabulated  as  the  causes  of  that  attack,  whereas  the  true  cause 
was  in  all  probability  far  removed  from  these  which  were  in 
reality  only  accidental  contemporaries.  In  reality  the  true 
underlying-  condition  in  all  these  cases  for  which  such  causes 
are  assigned  is  the  predisposition  to  insanity. 

In  other  words,  the  normal  mind,  under  the  influence  of 
stress,  does  not  become  deranged  unless  from  the  operation  of 
traumatism,  toxaemia,  or  extreme  degrees  of  exhaustion  and 
not  even  then  with  anything  like  the  facility  of  the  mind  pre- 
disposed to  disease  by  bad  heredity.  Ninety  per  cent,  is  in  all 
probability  not  far  from  the  truth  as  regards  the  number  of 
cases  of  insanity  presenting  hereditary  predisposition.  In  fact 
I  should  rather  expect  it  to  fall  below  the  truth  than  that  it 
were  an  exaggeration,  for  aside  from  certain  cases  produced 
by  the  causes  mentioned  above,  I  should  expect  it  to  enter  as 
a  factor  in  nearly  every  case. 

In  dealing  with  the  subject  of  heredity,  however,  we  must 
not  forget  that  our  ideas  are  of  necessity  largely  founded  upon 
theories,  as  biological  science  has  not  yet  unfolded  a  sufficient 
number  of  facts  to  make  it  possible  for  us  to  tell  just  how 
much,  in  any  individual  case,  must  be  attributed  to  the  inherent 
qualities  of  the  "germ  plasm"  and  just  how  much  to  the 
influences  of  environment. 

It  is  pretty  well  admitted  among  biologists  that  there  is  no 
sufficient  warrant  for  the  belief  in  the  Lamarckian  hypothesis 
of  the  inheritance  of  acquired  characters.  How,  for  example, 
could  one  possibly  conceive  that  a  special  aptitude  for  mathe- 
matics, or  the  manual  dexterity  of  the  graver  could  be  so  im- 
pressed upon  the  sexual  cells  that  these  special  traits  would 
reappear  in  the  offspring?  The  only  thing  we  can  conceive  of 
as  being  inherited  is  the  particular  make-up  of  the  individual 
that  made  the  acquirement  of  these  traits  possible. 


CAUSES  OF    MENTAL   DISORDERS.  2$ 

Although  the  sexual  cells  have  not  that  intimate  direct  con- 
nection with  the  different  parts  of  the  body  by  means  of  nerve 
currents  that  would  make  it  possible  for  a  change  occurring 
anywhere  to  be  reflected  in  them,  they  are  bathed  in  and  nour- 
ished by  the  body  fluids  and  we  might  expect  that  general  con- 
ditions producing  toxaemia  might  so  affect  them  as  in  some  way 
to  impair  their  functions  as  shown  in  the  resulting  offspring. 

Such  appears  to  be  the  case,  so  that  as  a  matter  of  fact  we 
find  not  infrequently  various  debilitating  and  toxic  conditions 
in  the  parents,  the  most  common  of  which  are  probably  tuber- 
culosis, alcoholism,  and  syphilis.  General  conditions  of  this 
sort  impair  the  germ  plasm  and  produce  defects  in  development 
as  a  result. 

While,  therefore,  we  not  infrequently  do  find  the  same  dis- 
ease developing  in  the  children  that  the  parents  suffered  from — 
the  heredity  is  similar — it  happens  more  frequently  that  gen- 
eral conditions  of  ill  health  in  the  ascendants  have  so  impaired 
the  germ  plasm  as  to  produce  conditions  of  instability  whigh 
may  show  itself  in  various  ways  other  than  in  reflecting  the 
same  disease — the  hereditary  is  dissimilar. 

Acquired  Predisposition. — The  two  most  important  agents 
in  bringing  about  an  acquired  predisposition  to  mental  derange- 
ment are  alcohol  and  syphilis,  while  tuberculosis  from  the 
prolonged  toxic-exhaustive  condition  it  brings  about  would 
probably  come  third.  All  of  these  causes,  the  first  two  espe- 
cially, may  by  acting  upon  the  normal  brain  bring  about  such 
changes  as  to  predispose  it  to  disease  and  thus  predispose  the 
individual  to  the  development  of  insanity.  It  must  not  be 
forgotten,  too,  that  the  occurrence  of  one  attack  of  mental  dis- 
order predisposes  to  subsequent  attacks. 

General:  Age. — According  to  the  Eleventh  Census  there  is 
a  gradual  increase  in  the  number  of  cases  of  insanity  from  the 
age  of  10  to  the  age  of  40.  From  40  on  there  is  a  gradual 
decrease.  The  table  given  is  very  interesting  and  worth  repro- 
ducing.    It  is  as  follows : 


24 


OUTLINES    OF    PSYCHIATRY. 


Age  Penod  when 

1890. 

1880. 

Age  Period  when 

1890. 

1900. 

Insanity  Appeared. 

Insanity  Appeared. 

IO-I5I 

39 

227 

55-60 

4.316 

940 

15-20 

790 

2,417 

60-65 

3,261 

652 

20-25 

3.138 

5.450 

65-70 

2,066 

358 

25-30 

5,704 

5,926 

70-75 

1,343 

186 

30-35 

8,123 

5,492 

75-80 

632 

90 

35-40 

8,182 

4,321 

80-85 

310 

23 

40-45 

7,930 

3,305 

85-90 

I02 

8 

45-50 

7,287 

2,405 

90-95 

38 

3 

50-55 

6,036 

1.542 

95  + 

3 

Physiological  Epochs. — The  periods  of  life  at  which  a  latent 
tendency  to  insanity  may  crop  out  are  the  physiological  epochs 
during  which  there  are  great  changes  going  on  in  the  general 
nutrition,  physiological  crises  in  fact.  These  physiological 
epochs  are  the  periods  of  puberty,  and  adolescence,  the  puer- 
perium,  the  climacterium  and  the  senium. 

Sex. — Although  insanity  is  about  equally  divided  between 
the  sexes  the  specially  dangerous  periods  in  the  female,  the 
puerperium  and  the  climacterium,  being  about  balanced  by  the 
results  of  alcohol  and  syphilis  and  a  more  strenuous  mental 
life  in  the  male,  yet  the  U.  S.  Census  seems  to  show  a  tendency 
to  a  gradual  increase  in  the  percentage  of  males  as  shown  by 
the  following  table : 


Per  Cent.  Distribution  of 

Sex. 

General  Population. 

Insane  Enumeration  in  Hospitals. 

1900. 

1890. 

1880. 

December 
31.  i9°3- 

June  I, 

1890. 

June  I, 

188c;. 

Both  sexes. 

100 

100 

100 

100 

100 

100 

Males. 
Females. 

48.9 

51.2 
48.8 

50.9 
49.1 

52-3 
47.7 

51.8 
48.2 

50.4 
49.6 

Civil  Condition. — The  percentage  of  insanity  is  greater  in 
the  unmarried  than  in  the  married.  The  Census  returns  for 
all  the  insane  in  hospitals  in  1904  show  50.1  per  cent,  to  have 
been  single,  leaving  the  balance  of  49.9  per  cent,  to  be  divided 
among  married,  widowed,  divorced,  and  unknown. 

*In  1880  this  age  period  was  12  to  15  years. 


CAUSES   OF   MENTAL  DISORDERS.  2$ 

Climate. — The  only  effect  of  climate  is  to  supply  conditions 
which  make  exhaustion  and  infection  more  liable.  The  cli- 
mate itself  has  no  direct  effect.  Malaria,  yellow  fever,  and 
other  diseases  of  tropical  climates  produce  a  condition  of 
toxaemia  and  exhaustion  favorable  to  the  outcrop  of  mental 
diseases,  while  the  extreme  heat  makes  physical  exertion  more 
exhausting  and  the  effects  of  alcohol  are  not  so  well  borne. 

Civilisation. — Insanity  is  most  prevalent  among  the  most 
highly  civilized.  In  the  process  of  evolution  the  struggle  for 
existence  has  changed  from  a  physical  to  a  mental  struggle  and 
as  it  is  the  organ  most  used  that  is  most  open  to  the  dangers 
of  accident  and  disease  so  we  find  the  brain  giving  way  more 
frequently  as  the  stresses  of  life  become  more  and  more  mental 
rather  than  physical.  Thus  we  find  not  only  that  insanity  is 
most  prevalent  among  the  most  highly  civilized,  but  among 
these  it  is  found  with  greatest  frequency  in  the  immense,  con- 
gested centers  of  population  where  civilization  has  reached  its 
greatest  development  and  the  struggle  for  existence  become 
most  severe. 

Exciting  Causes. 

Predisposition  alone,  however,  is  usually  not  sufficient  to 
produce  insanity,  especially  is  this  true  of  an  acquired  pre- 
disposition such  as  that  induced  by  alcohol,  syphilis,  and  tuber- 
culosis without  the  element  of  mental  stress  added.  This  is 
well  illustrated  by  the  condition  of  the  American  Indian. 
Sorely  afflicted  as  he  is  by  the  diseases  and  vices  of  civilization, 
his  tendency  is  to  an  outdoor  life,  and  as  his  land  has  dis- 
appeared and  he  has  become  physically  incapacitated,  the  gov- 
ernment has  supported  him,  so  that  his  sufferings  have  been 
in  the  main  physical  and  not  mental.  Careless,  slovenly,  and 
improvident,  he  does  not  know  much  of  worry  for  the  morrow, 
and  so  we  rarely  find  insanity  in  his  race. 

Physical:  Toxic. — The  various  poisons  which  may  act  as 
exciting  causes  of  insanity  may  be  either  exogenous — coming 
from  without — or  endogenous — originating  within  the  body. 


26  OUTLINES    OF    PSYCHIATRY. 

Of  the  exogenous  variety  alcohol  is  perhaps  the  most  promi- 
nent. It  is  probably  responsible  for  from  fifteen  to  twenty  per 
cent,  of  cases  in  males.  Alcohol  and  syphilis  together,  if  we 
include  paresis  as  a  syphilitic  disease,  are  responsible  for  fully 
twenty  per  cent,  of  the  insanity  in  males  at  least.  Some  of  the 
other  poisons  that  belong  in  this  group  are  opium  (morphine), 
cocaipe,  atropine  and  its  isomers,  lead  and  mercury,  while  the 
toxines  of  various  diseases  such  as  syphilis,  tuberculosis,  typhoid, 
yellow  fever,  malaria,  and  grippe  frequently  act  as  exciting 
causes.  Of  the  endogenous  poisons  the  most  important  are 
those  which  originate  from  the  gastro-intestinal  tract,  and  as  a 
result  of  chronic  nephritis.  The  mental  disorders  which  ac- 
company such  diseases  as  myxedema,  exophthalmic  goitre,  and 
acromegaly  probably  belong  here  also. 

Traumatic. — Direct  injuries  to  the  head,  such  as  bullet 
wounds  and  fracture,  are  of  course  not  infrequently  the  imme- 
diate cause  of  mental  disorder,  while  more  indirect  injuries, 
such  as  concussion  from  falls,  transmitted  perhaps  through  the 
spine,  may  also  be  the  starting  point  of  insanity. 

Exhaustion. — Exhaustion  from  prolonged  physical  and  men- 
tal strain,  from  chronic  diseases,  or  as  the  result  of  acute  con- 
ditions following  fevers,  or  the  result  of  sudden  loss  of  consid- 
erable blood,  may  be  prominent  exciting  causes.  It  is  to  be 
remembered  in  this  connection  that  exhaustion,  especially 
physical,  results  in  and  may  in  large  part  produce  its  effects  by 
the  development  of  toxic  substances,  as  for  instance  from  the 
breaking  down  of  muscle. 

Bodily  Diseases. — Bodily  diseases  other  than  those  develop- 
ing poisons  may  act  as  causes  by  disturbances  of  circulation, 
reflex  irritation,  disturbances  of  nutrition  and  exhaustion. 
Such  are  cardiac  diseases  with  broken  compensation,  the  reflex 
irritation  from  intestinal  parasites,  and  the  various  nervous  dis- 
eases which  often  have  mental  symptoms  connected  with  them, 
such  as  epilepsy,  chorea,  hysteria. 

Mental. — Any  severe  mental  stress  may  act  as  an  exciting 
cause  of  insanity.     A  sudden  emotional  shock,  such  as  fright, 


CAUSES  OF   MENTAL  DISORDERS,  2/ 

or  the  horror  resulting  from  the  terrible  sights  of  the  wounded 
and  dying  in  a  railroad  wreck,  may  induce  an  outbreak  of 
mental  disorder,  while  the  less  acute  conditions  of  worry  and 
anxiety,  usually  acting  over  a  considerable  period  of  time,  may 
also  be  etiological  factors  in  the  development  of  a  psychosis. 


CHAPTER  V. 
TREATMENT. 

In  the  treatment  of  the  insane  the  general  principles  of 
therapeutics  are  of  course  applicable  as  in  other  departments 
of  medicine.  Disorders  of  the  various  organs  are  found 
among  the  insane  as  among  the  sane  and  require  the  same  sort 
of  treatment.  It  is  only  intended  in  this  chapter  to  devote  a 
few  words  to  the  discussion  of  the  therapeutics  of  insanity  in 
so  far  as  it  differs  from  therapeutics  as  ordinarily  resorted  to, 
for  there  are  conditions  commonly  met  with  among  the  insane 
that  require  treatment  that  are  rare  or  absent  among  the 
sane.  Excitement,  agitation  and  violence,  for  example,  may 
occur  in  the  delirium  of  fever  but  is  of  short  duration — transi- 
tory— while  in  the  realm  of  mental  disease  this  condition  may 
persist  for  weeks  and  require  treatment.  Only  certain  general 
considerations  will  be  taken  up  here,  while  special  matters  per- 
taining to  the  different  psychoses  will  be  discussed  in  their 
appropriate  places. 

Hydrotherapy. — It  is  impracticable  here  to  take  up  a  full 
discussion  of  this  subject.  The  student  should  consult  special 
works  for  detailed  information.  It  may  be  said,  however,  that 
the  various  forms  of  hydrotherapeutic  devices  form  one  of  the 
more  valuable  of  the  recent  additions  to  the  means  of  treating 
insanity.  This  is  true  especially  of  the  treatment  of  the  excite- 
ments. In  the  absence  of  hydrotherapy  the  only  w^ay  to  deal 
with  these  cases  is  by  manual  or  mechanical  restraint,  or  by 
chemical  restraint.  All  of  these  means  are  undesirable  if 
avoidable.  With  a  well  equipped  hydrotherapeutic  outfit,  how- 
ever, their  use  may  be  reduced  to  a  minimum. 

Such  an  equipment  would  provide  for  the  giving  of  hot 
baths — local  or  general :  full  baths,  simple  or  medicated,  at 


TREATMENT.  29 

various  temperatures:  needle,  rain,  fan,  spray,  jet,  spinal  and 
Scotch  douches,  regulated  as  to  temperature  and  pressure :  wet 
packs,  hot  or  cold :  sitz  baths,  etc. 

These  various  measures  have  eliminating,  stimulating,  or 
sedative  effects,  according  to  circumstances.  For  toxic  states, 
such  as  chronic  alcoholism,  the  stimulating  effect  of  the  hot  air 
with  profuse  sweating,  followed  by  the  stimulating  effects  of 
the  Scotch  douche,  are  very  valuable,  while  in  excited  cases 
some  form  of  wet  pack  gives  better  results.  In  applying  the 
wet  pack  the  wet  sheet  is  put  on  first  after  being  sufficiently 
wrung  out,  usually  of  cold  water,  so  as  not  to  drip,  carefully 
wrapped  about  the  patient  and  tucked  in,  then  a  dry  blanket  is 
rolled  about  the  patient  and  also  carefully  tucked  in  at  the 
arms,  made  snug  at  the  neck,  and  turned  in  at  the  foot,  so  that 
no  draft  can  strike  any  portion  of  the  wet  body  and  neither 
arm  nor  leg  can  be  voluntarily  exposed  by  the  patient.  When 
skillfully  applied  it  affords  a  sufficient  restraint  to  the  patient 
until  the  sedative  effect  is  manifest.  Excited  cases  treated  in 
this  way  with  a  cold  cloth  or  ice  cap  to  the  head  often  quiet 
down  surprisingly  and  not  infrequently  go  to  sleep.  The  great 
advantage  of  this  method  is  that  it  can  be  used  in  the  home. 

The  warm  bath  of  a  few  minutes  duration  is  also  a  very 
valuable  sedative  that  can  be  used  at  home,  but  if  used  care 
should  be  taken  to  watch  the  heart  if  the  patient  is  weak  and 
when  the  bath  is  over  the  patient  should  be  rapidly  wiped  off, 
wrapped  up  in  blankets  and  put  to  bed  without  any  exposure  to 
drafts  or  cooling. 

Continuous  Bath. — The  continuous  bath  is  used  for  the 
most  part  in  the  treatment  of  the  active  and  excited  cases.  The 
tub  is  made  somewhat  longer  than  usual  to  accommodate  the 
patient  at  full  length  comfortably.  The  patient  is  placed  in 
the  tub  (if  desired  he  may  rest  in  a  canvas  hammock  attached 
to  the  sides),  the  water  being  kept  by  means  of  a  regulating 
apparatus  at  about  95°  F.  The  bath  may  be  prolonged  for 
several  hours,  in  fact  the  patient  may  spend  all  day  in  the  bath. 
In  Germany,   where  this   form  of  treatment  originated,   the 


30  OUTLINES    OF    PSYCHIATRY. 

patients  are  often  kept  continuously  in  the  bath  not  only  for 
hours  but  for  days  and  weeks  at  a  time,  eating-  and  sleeping 
there.  It  is  remarkable  that  many  of  these  disturbed  cases 
seem  after  a  time  to  like  the  warm  sedative  influence  of  the 
water,  and  I  have  seen  a  patient  cry  to  go  back  in  the  tub  after 
she  had  been  taken  out. 

Another  great  advantage  of  the  continuous  bath  is  the  good 
efifect  the  water  has  upon  the  skin.  The  warm  water  keeps  it 
soft  and  active  and  the  tendency  which  exists  in  so  many  cases, 
particularly  of  paresis,  to  the  development  of  bed-sores  is 
largely  prevented;  the  patient  resting  in  a  medium  of  consid- 
erably higher  specific  gravity  than  the  air  a  large  proportion 
of  the  pressure  is  thus  removed  from  the  skin,  so  alleviating 
one  of  the  most  prominent  causes. 

Refusal  of  Food. — This  is  one  of  the  most  annoying  symp- 
toms met  with  and  yet  is  quite  common  among  the  depressed 
insane.  It  frequently  has  a  serious  influence  upon  the  health 
of  the  patient,  so  it  becomes  of  the  highest  importance  to  know 
how  to  meet  it. 

If  the  patient  be  in  good  physical  condition  it  is  wise  to  let 
him  go  for  a  time  without  food  in  the  hope  that  the  cravings 
of  hunger  will  force  him  to  eat,  as  once  artificial  feeding  is 
begun  it  is  liable  to  have  to  be  continued.  A  strong,  vigor- 
ous patient  may  be  permitted  to  fast  thus  for  as  long  as  three 
days,  while  on  the  other  hand,  it  frequently  happens  that  when 
the  patient  is  first  seen  he  has  already  been  temporized  with  so 
long  that  he  is  in  such  condition  as  to  require  feeding  at  once. 

There  are  many  methods  of  artificial  feeding,  but  the  method 
of  tube-feeding  is  the  only  one  that  merits  much  attention. 
This  method  may  be  employed  either  by  the  nasal  or  the 
esophageal  route. 

The  esophageal  route  is  always  to  be  preferred.  The  patient 
is  fed  sitting  up  in  a  firmly  constructed,  straight-backed  arm- 
chair, unless  a  greatly  enfeebled  condition  renders  the  position 
on  the  back  imperative.  The  operator  stands  behind  and 
gently  forces  the  mouth  open  with  a  soft  wooden  wedge  intro- 


TREATMENT.  3 1 

duced  on  the  left  side,  then  with  the  patient's  head  held  under 
his  left  arm  he  holds  the  wedge  with  his  left  hand,  which  is 
steadied  by  placing  his  little  finger  under  the  patient's  chin. 
The  patient's  head  thus  secured,  the  arms  and  legs  held  by 
nurses,  if  necessary,  the  esophageal  tube  is  dipped  in  the  milk 
to  be  given  and  passed.  A  funnel,  preferably  vulcanized 
rubber,  is  now  inserted  in  the  tube  by  a  nurse  and  the  food 
slowly  poured  in. 

The  same  position  is  assumed  for  passing  the  nasal  tube. 
The  tube  used  may  be  an  ordinary  male  catheter.  Before 
attempting  to  pass  it  it  is  well  to  examine  the  nose,  particularly 
for  polypi  and  deflected  septum,  and  choose  the  side  which 
will  present  the  least  obstruction.  The  tube  then  being  dipped 
in  the  milk  to  lubricate  it  is  passed  along  the  floor  of  the  nostril 
and  down  into  the  esophagus.  Care  must  be  taken  to  see  that 
it  does  not  enter  the  larynx.  If  it  should,  the  usual  signs  are 
severe  strangling,  coughing  and  cyanosis,  while  the  air  may 
be  heard  making  a  rushing  sound  as  it  passes  in  and  out  of  the 
tube.  It  must  not  be  forgotten,  however,  that  in  some  cases, 
particularly  in  paresis,  there  is  more  or  less  anesthesia  of  the 
larynx  and  these  signs  may  be  in  large  measure  absent.  It  is 
well,  therefore,  after  the  tube  is  passed  to  wait  a  few  moments 
and  see  if  the  patient  does  respire  through  it,  not  forgetting 
that  immediately  after  it  first  enters  the  esophagus  a  little  rush 
of  gas  may  escape  through  it  from  the  stomach.  The  tube 
being  passed,  the  food  may  be  introduced  through  a  funnel  by 
gravity,  as  with  the  esophageal  tube,  but  as  this  is  a  very  slow 
process,  owing  to  the  small  calibre  of  the  tube,  it  is  more  sat- 
isfactory to  attach  a  Davidson  syringe,  first  filling  it  with  the 
milk  so  as  not  to  inject  air,  and  then  gradually  pump  the  food 
through  this. 

In  withdrawing  the  tube  it  should  be  pinched  tightly  to  pre- 
vent a  leakage  as  the  end  passes  over  the  larynx. 

The  nasal  tube  is  preferable  particularly  with  those  patients 
who  resist  very  actively  and  who  have  a  good  set  of  teeth  that 
the   introduction   of   the   wedge   may   injure.     It   is   contra- 


32  OUTLINES    OF    PSYCHIATRY. 

indicated  in  cases  of  nasal  disease  and  obstruction,  while  it  is 
best  to  avoid  its  use  if  possible  when  there  is  anesthesia  of  the 
larynx. 

The  esophageal  tube  should  be  avoided  when  there  is  disease 
of  the  esophagus  or  cardia  and  in  some  cases  of  feeble  heart 
action  when  the  nasal  tube  can  be  passed  with  less  commotion. 

The  usual  mixture  for  feeding  is  a  pint  to  a  pint  and  a  half 
of  milk  to  which  is  added  two  eggs.  In  addition  there  may 
be  added  beef  juices  or  other  forms  of  liquid  food  and  various 
medicines,  particularly  cathartics  and  hypnotics  with  the  even- 
ing feeding. 

Feeding  should  be  done  at  least  twice  daily — morning  and 
evening.  If  the  food  is  not  well  digested  oftener  and  in 
smaller  amounts. 

Medication. — As  the  various  insanities  are  for  the  most  part 
relatively  chronic  diseases,  great  care  should  be  used  in  pre- 
scribing opium  or  any  of  its  alkaloids,  as  otherwise  a  serious 
addiction  may  be  encouraged. 

One  of  the  most  frequent  conditions  which  has  to  be  met 
with  by  drugs  is  insomnia.  This  is  a  symptom  in  many  of  the 
psychoses  and  often  over  a  considerable  period  of  time.  Of 
the  various  hypnotics  paraldehyde  is  one  of  the  best,  but  of 
course  is  greatly  limited  in  its  use  because  of  its  very  disagree- 
able odor  and  taste.  Sulfonal  is  an  excellent  hypnotic,  but 
somewhat  slow  in  its  action.  It  is  best  given  at  supper  time 
and  then  will  be  active  about  bed  time.  It  may  be  given  to 
patients  who  refuse  medicine  by  mixing  with  apple  sauce,  for 
example,  as  it  has  little  taste.  Its  prolonged  use  should  be 
avoided,  as  poisoning  may  occur  with  hematoporphyrinuria. 
Trional  is  equally  as  good  a  hypnotic  and  acts  more  promptly. 
In  some  cases  in  which  the  patient  wakes  up  in  the  small  hours 
of  the  morning  a  mixture  of  sulfonal  and  trional  may  be  given, 
about  15  grs.  each,  at  bed  time.  The  trional  will  act  the  early 
part  of  the  night  and  the  sulfonal  the  latter. 

Chloralamid  is  a  similar  drug  and  may  be  given  in  a  pleasant 
elixir,  while  in  some  more  troublesome  cases  chloral  may  be 
indicated. 


TREATMENT.  33 

In  the  use  of  hypnotics  care  should  be  taken  to  interrupt 
the  administration  from  time  to  time  to  see  if  normal  sleep  will 
not  supervene  and  also  to  change  from  one  to  the  other  to  pre- 
vent cumulative  effects  or  addiction.  It  is  of  course  under- 
stood that  hypnotics  should  be  resorted  to  only  when  other 
means  have  failed. 

In  the  acutely  excited  conditions  requiring  sedatives  about 
the  only  drugs  that  are  efficient  are  the  alkaloids  of  hyoscy- 
amus,  given  hypodermically.  Great  care  should  be  exercised 
in  using  this  drug,  as  the  various  preparations  are  somewhat 
uncertain.  The  chemically  pure  alkaloids  have  not  been  so 
successful  in  my  hands  as  the  amorphous  sulphate  of  hyoscy- 
amine  (Merck),  which  contains  a  mixture  of  the  alkaloids. 
This  drug  may  be  given  hypodermically  in  doses  as  high  of 
i/io  gr.,  or  in  a  strong,  vigorous  person  without  cardio- 
vascular disease,  i/8  gr.  Its  action  seems  to  be  assisted  by 
3  or  4  gtts.  of  Magendie's  solution.  It  must  be  remembered 
that  the  pure  alkaloids  must  not  be  administered  in  any  such 
doses — usually  not  over  1/100-1/50  gr.  Too  small  doses  of 
the  drug  may  not  quiet  the  patient  at  all,  but  on  the  other 
hand  only  produce  a  degree  of  belladonna  delirium. 

Here,  as  with  the  hypnotics,  drugs  should  not  be  used  until 
other  means  have  failed. 

In  regard  to  the  whole  subject  of  the  giving  of  drugs,  too 
much  emphasis  cannot  be  placed  on  the  caution  to  avoid  over- 
medication.  It  is  not  an  uncommon  thing  to  see  patients 
admitted  into  a  hospital  suffering  from  the  toxic  effects  of 
drugs,  usually  bromides  and  chloral.  In  this  condition  they 
not  only  suffer  the  deleterious  effects  of  the  toxemia,  but  the 
symptoms  of  the  disease  from  which  they  are  suffering  may  be 
hopelessly  clouded. 


CHAPTER   VI. 
GENERAL  SYMPTOMATOLOGY. 

In  describing  the  general  symptoms  of  insanity  the  scheme 
of  the  several  mental  processes  outlined  in  the  preceding  chap- 
ters will  be  adhered  to  and  the  principal  disorders  of  each  taken 

/NTRAPSYCHtC 


S  =  SCNSORr    PROJECTION    FlCLO 

M"  MOTOR     PROJECTION    FIELD 

A=  INITIAL     IDEA 

Z  =■  TERMINAL    IDEA 

Fig.  2.    Showing  subdivisions  of  mental  processes. 

up  in  turn.  Certain  symptoms,  however,  associated  more  par- 
ticularly with  special  psychoses,  will  be  left  and  discussed  in 
the  chapter  in  which  that  particular  psychosis  is  described. 

Before  going  on  to  the  discussion  of  the  special  symptoms 
it  may  be  well  first  to  call  attention  to  a  slight  modification  of 

34 


GENERAL   SYMPTOMATOLOGY.  35 

the  diagram  used  previously  to  illustrate  the  mental  processes 
for  the  purpose  of  illustrating  some  general  principles  involved. 
(See  Fig.  2.) 

In  this  diagram  everything  from  ^  to  M,  inclusive,  is  in- 
cluded in  consciousness,  the  term  used  to  denote  the  sum  total 
of  mental  life.  This  is  indicated  by  the  term  used :  for  exam- 
ple, psychomotor  would  refer  to  motor  acts  originating  in 
consciousness.  A  reflex  act  would  thus  not  be  included — it 
is  not  a  psychomotor  act,  taking  place  entirely  without  the 
realm  of  consciousness.  Taking  then  this  tripartite  division  of 
consciousness,  we  may  follow  Wernicke  and  say  that  in  each 
of  the  three  territories  there  may  be  three  types  of  disorder, 
as  follows: 

Psychosensory.  Intrapsychic.  Psychomotor. 

Anesthesia.  Afunction.  Akinesis. 

Hyperesthesia.  Hyperfunction.  Hyperkinesis. 

Paresthesia.  Parafunction.  Parakinesis. 

Bearing  these  general  principles  in  mind,  we  will  proceed 
now  to  the  discussion  of  the  special  symptoms. 

Disorders  of  Perception. 

Illusions. — An  illusion  is  an  inexact,  or  inaccurate,  percep- 
tion. The  information  conveyed  to  the  mind  by  the  sense 
organ  is  misinterpreted,  so  that  the  source  of  the  sensory  im- 
pressions in  the  environment  is  not  appreciated  at  its  true 
value.  A  strap  lying  on  the  floor  may  be  perceived  as  a  snake, 
the  sighing  of  the  wind  may  be  perceived  as  the  whispering 
of  a  human  voice,  a  bad  taste  in  the  mouth  may  be  perceived 
as  poison,  and  so  on  throughout  the  different  sensory  realms. 
The  distinguishing  thing  about  an  illusion  is  that  an  actual 
something  in  the  environment  is  perceived  but  the  perception 
is  not  a  correct  one  and  conveys  false  information  to  the  mind. 

Hallucinations. — An  hallucination,  on  the  other  hand,  is 
generally  conceived  to  be  a  perception  without  sensory  founda- 
tion in  the  environment.     A  snake  is  seen  on  the  floor  where 


36  OUTLINES    OF    PSYCHIATRY. 

there  is  nothing  which  could  be  mistaken  for  a  snake,  the  floor 
is  bare;  human  voices  are  heard  where  there  are  actually  no 
sounds  in  the  environment  which  could  be  interpreted  as  such ; 
poison  is  tasted  where  there  has  been  nothing  in  the  food  or 
mouth  which  has  given  origin  to  the  taste.  The  distinguish- 
ing feature  of  an  hallucination  then  is  a  perception  without 
there  being  anything  in  the  environment  to  perceive. 

Recent  studies,  however,  have  made  it  highly  probable  that 
a  large  number  of  what  have  been  supposed  to  be  hallucina- 
tions are  in  reality  dependent  upon  pathological,  or  even  at 
times  physiological  processes  occurring  in  the  sensory  end 
organs,  so  that,  with  reference  to  the  eye  and  ear,  for  ex- 
ample, they  might  be  said  to  be  of  entoptic  or  entotic,  origin 
respectively. 

So  far,  however,  as  any  given  erroneous  perception  is  con- 
cerned it  really  matters  little  from  the  point  of  view  as  to  its 
significance  as  a  symptom  of  mental  disease,  whether  it  be 
classed  as  an  illusion  or  an  hallucination.  The  mental  process 
in  both  instances  is  identical.  In  practical  use  the  two  are  not 
often  distinguished,  but  false  perceptions  are  generally  spoken 
of  as  hallucinations  and  as  the  mental  process  is  the  same  in 
both  hallucination  and  illusion  the  necessity  for  their  distinc- 
tion does  not  arise  and  the  use  of  the  term  hallucination  serves 
the  purpose  very  well. 

Using  the  term  hallucination  then  to  include  the  phenomena 
of  illusion,  there  are  a  number  of  considerations  to  take  up 
regarding  their  different  forms  and  their  manifestations  in  the 
various  sensory  areas. 

Pseudo-hallucinations.  —  Pseudo-hallucinations,  also  called 
psychic  and  apperception  hallucinations,  seem  to  occupy  a  posi- 
tion midway  between  imagination  and  the  fully  developed  form 
of  hallucination.  The  patient  does  not  have  the  same  convic- 
tion of  their  external  reality  and  may  even  appreciate  their 
subjective  nature  while  still  believing  them  to  be  brought  about 
by  external  agencies,  i.  e.,  God  or  his  enemies — as  in  the  case 
cited  by  Kandinsky  of  the  patient  who  had  a  pseudo-hallucina- 


GENERAL   SYMPTOMATOLOGY.  37 

tion  of  a  lion  which  appeared  to  him  and  laid  his  forepaws  on 
his  shoulder.  The  patient  appreciated  that  he  saw  the  lion 
only  with  his  mind's  eye  and  was  not  afraid  as  he  otherwise 
would  have  been,  and  interpreted  the  vision  as  signifying  his 
allegiance  to  England. 

Pseudo-hallucination  differs  from  imagination  in  the  fact 
that  the  sensory  elements  have  a  greater  objectivity  and  occur 
independently  of  the  volition  of  the  subject.  They,  in  general, 
differ  from  hallucinations  in  having  somewhat  less  objective 
reality  and  further  are  more  often  in  consistent  harmony  with 
the  content  of  consciousness — do  not  obtrude  themselves  sud- 
denly and  unexpectedly  into  the  field  of  consciousness  as  hallu- 
cinations often  do,  particularly  auditory  hallucinations.  They 
not  infrequently  involve  two  or  more  sensory  areas  and  con- 
stitute an  element  in  the  so-called  dream  states. 

Hypnagogic  Hallucinations. — These  are  hallucinations  which 
occur  in  the  intermediate  state  between  sleeping  and  waking. 
Their  principal  importance  for  us  lies  in  the  fact  that  they  may 
readily  be  mistaken  for  hallucinations  occurring  in  the  waking 
state.  If  the  possibility  of  confusion  is  kept  in  mind  the  dif- 
ferentiation can  usually  be  made  without  trouble.  The  fol- 
lowing case  illustrates  this  condition  and  the  principles  of 
differentiation : 

The  patient,  a  middle-aged  man,  claims  to  have  numerous 
visions.  He  has  been  a  spiritualist  for  years  and  often  sees 
visions  of  deceased  persons.  He  describes  one  occurrence 
when  he  had  a  vision  as  follows  :  "  I  went  into  the  cellarway  to 
fill  my  lamp,  and  after  filling  the  lamp  I  saw  the  road  from 
Catherine  Holliday's  north  to  the  county  line.  There  was  no 
significance  attached  to  that,  but  I  sat  there  and  presently  I 
saw  a  hand ;  a  chubby  kind  of  fleshy  hand  and  the  finger  nail 
was  grown  down  over  the  end  of  the  front  finger  a  little  over 
a  quarter  of  an  inch  wide,  but  it  grew  clear  over  the  end  of  the 
finger.  I  said  that  is  a  funny  finger,  and  I  sat  a  second  more 
and  I  heard  the  v/ords,  Ezra  Perkins,  and  I  says,  *  why,  I  know 
Ezra  Perkins.'     Presently  all  was  changed  and  I  saw  a  house, 


38  OUTLINES    OF    PSYCHIATRY. 

door  opening  to  the  east.  In  one  room  was  a  ground  floor  and 
a  wood  bench;  then  I  saw  a  small  room  with  a  painted  floor, 
painted  yellow,  a  small  bedstead  with  no  banisters  or  curtains 
around ;  on  the  edge  of  the  bed  I  saw  a  small  manila  cord  or 
rope.  Then  I  looked  as  though  I  were  passing  by  buildings 
and  I  saw  a  house.  On  the  north  part  of  the  building  the 
blinds  seemed  to  be  red  and  dark;  the  south  part  were  green 
and  there  were  flowers  in  the  windows.  Then  I  saw  Hiram 
Brinsmead  apparently  coming  out  to  the  road.  Then  I  saw  a 
small  boy  with  light  hair.  Then  I  saw  the  interior  of  a  room 
on  the  east  side  of  the  house,  a  lady  reclining  on  the  bed  bol- 
stered up  on  some  pillows.  She  lay  quartering  across  the  bed 
from  the  southeast  to  northwest.  She  had  a  pink  dress  on, 
made  plain  with  the  exception  of  a  ruffle  or  goring  piece 
around  the  sleeves  and  the  same  around  the  skirt  bound  around 
with  white,  and  was  reading  the  Bible. 

"  That  is  all  there  is  of  that  only  it  is  imperfect,  but  it  is 
worded  just  as  I  can  recall  it." 
^  This  description  bears  on  its  face  certain  evidences  of  the 
dream  state.  The  sudden  shifting  of  the  scene  and  the  follow- 
ing of  one  event  upon  another  without  any  apparent  reason 
for  the  association  is  characteristic  of  dreams.  Further  than 
this,  it  is  to  be  noted  that  the  surroundings  were  favorabl.e  to 
sleep.  The  percipient  starts  to  fill  his  lamp  during  the  latter 
part  of  the  afternoon,  he  sits  down  on  the  landing  after  it  is  ( 
done  (this  would  indicate  that  he  must  have  been  tired).  He  '; 
is  sitting  in  this  position  when  the  visions  appear.  He  must 
have  sat  there,  at  his  own  estimation,  for  about  twenty  minutes, 
for  when  he  arose  he  saw  it  was  just  getting  dark  and  it  was 
quite  light  when  he  sat  down.  It  is  also  noteworthy  in  this 
case  that  descriptions  of  visions  taken  at  considerable  intervals 
vary  considerably  and  this  variation  is  most  marked  in  the 
direction  of  forgetfulness,  the  later  descriptions  showing  a 
tendency  to  omit  many  of  the  facts  contained  in  the  former, 
although  there  is  also  a  tendency  to  include  certain  other  in- 
stances not  at  first  mentioned.     This  latter  tendency  is,  how- 


GENERAL   SYMPTOMATOLOGY.  39 

ever,  not  so  marked.  The  former  tendency  is  quite  charac- 
teristic of  dreams,  as  any  one  can  testify  to  his  own  satisfac- 
tion who  has  ever  had  occasion  to  recall  a  dream.  A  dream 
which  on  awakening  in  the  morning  may  be  quite  well  remem- 
bered, is  in  the  course  of  a  few  days  or  even  hours  quite  hazy 
in  its  outlines,  if  no  efforts  have  been  made  in  the  meantime  to 
recall  it.  The  latter  tendency  is  equally  characteristic  of 
amnesic  states  generally. 

In  addition  to  the  above  reason  for  considering  these  visions 
as  having  occurred  in  a  dream  state  of  consciousness,  the  per- 
cipient states  that  at  one  time,  while  describing  these  same 
visions,  that  after  they  had  passed  he  arose  and  stretched  him- 
self, a  very  common  evidence  of  having  been  asleep.  He  de- 
nied this,  however,  afterwards.  He  also  describes  one  other 
vision  after  which  he  had  a  "  sort  of  tired  feeling "  for  a 
minute  or  two  which,  however,  soon  passed  away. 

Auditory  Hallucinations. — When  these  are  elementary,  that 
is,  are  largely  sensory  in  character  with  few  associations,  they 
are  known  as  akoasms.  Such  would  be  simple  sounds,  as 
buzzing,  crackling,  ringing,  and  the  like.  The  more  compli- 
cat'ed  hallucinations  which  are  conceived  by  the  patient  to  be 
"voices"  —  verbal  auditory  hallucinations  —  are  known  as 
phonemes. 

The  "  voices  "  say  pleasant  or  unpleasant  things  but  usually 
the  character  of  the  remarks  are  consistent  throughout  and  in 
harmony  with  the  general  mental  condition  of  the  patient. 
They  may  be  heard  in  both  ears  or  in  only  one  ear  and  be  of 
any  timbre.  Rarely  different  voices  are  heard  in  the  two  ears, 
as  in  one  of  my  patients  who  heard  Christ  talking  to  her  in 
her  right  ear  and  the  Devil  in  her  left.  The  "  voices  "  may 
be  located  externally  or  on  the  contrary  be  heard  coming  from 
different  parts  of  the  body,  i.  e.,  the  "  epigastric  voice."  Some- 
times the  patient,  when  closely  questioned,  will  say  that  they 
do  not  hear  any  sound,  any  spoken  word,  but  as  described  by 
one  of  my  hallucinated  cases,  "it  was  more  as  if  they  con- 
versed with  her  directly  through  her  mind." 


40  OUTLINES    OF    PSYCHIATRY. 

More  obscure  conditions  are  those  in  which  the  patient  be- 
Heves  that  his  thoughts  become  audible,  that  he  can  hear  his 
thoughts  before  he  can  speak  them. 

In  patients  suffering  from  auditory  hallucinations,  ear  dis- 
ease resulting  in  various  degrees  of  deafness  is  common. 

Visual  Hallucinations. — Elementary  hallucinations,  in  which 
the  sensory  element  is  maximal  and  the  association  element 
minimal — photomata — occur  as  flashes  of  light,  sparks,  colors, 
and  the  like.  All  degrees  of  elaboration  occur  from  these 
simple  conditions  to  the  most  complex  visions.  Hallucinations 
of  sight  are  more  apt  to  be  pleasant  than  those  of  hearing,  but 
they  too  are  frequently  disagreeable,  often  terrifying,  as  visions 
of  hell  and  of  all  sorts  of  noxious  creatures  so  common  in  the 
various  deliria.  Visual  hallucinations  occur  not  infrequently 
in  the  blind. 

Hallucinations  of  Taste  and  Smell. — Hallucinations  of  these 
two  senses  are  quite  apt  to  be  associated  and  are  almost 
uniformly  disagreeable,  as  in  one  of  my  cases,  a  middle- 
aged  woman,  who  claimed  she  smelled  and  tasted  the  blood 
of  people  who  were  killed  in  the  hospital.  The  blood  was 
smelled  when  the  meals  were  being  cooked  and  tasted  at  meal 
time  in  the  food.  Poison  is  frequently  complained  of  as 
being  tasted  in  the  food  and  noxious  and  poisonous  vapors 
are  often  smelled. 

Haptic  Halluciriations. — The  various  special  senses  located 
in  the  skin — touch,  pain,  heat  and  cold — may  be  the  subject 
of  hallucinations.  The  most  common  are  indefinite  disturb- 
ances of  the  nature  of  paresthesia,  hallucinations  of  animals 
crawling  over  the  skin  (deliria),  or  under  the  skin,  particu- 
larly at  the  finger  tips  (cocainism).  Hallucinations  of  touch 
are  not  uncommon,  but  are  usually  associated  with  other  dis- 
orders of  perception. 

Hallucinations  of  the  Organic  Sensations. — The  most  com- 
mon of  these  are  peculiar  and  often  indescribable  sensations 
coming  from  the  internal  organs  and  giving  rise  to  such  beliefs 
as :  the  bones  are  broken,  the  brain  dried  up,  an  immense  tape- 


GENERAL   SYMPTOMATOLOGY.  4^ 

worm  is  coiled  up  in  the  lungs,  the  bowels  are  stopped  up,  there 
is  no  stomach,  and  the  like. 

Disturbances  in  the  realm  of  the  sexual  sensations  also  belong 
under  this  head  and  lead  to  such  ideas  in  women  as  that  they 
are  violated  while  they  sleep,  and  in  men  that  their  organs  are 
abused  and  their  semen  drawn  off. 

Kinesthetic  or  Motor  Hallucinations. — These  are  sensations 
of  movement  of  some  sort.  The  sensations  from  muscles, 
joints  and  tendons  may  be  involved,  as  may  also  the  static 
sense,  owing  to  labyrinthine  disturbance.  Disturbances  in 
these  sensory  areas  give  rise  to  hallucinations  leading  to  the 
belief  that  the  body  has  undergone  a  change  in  position.  One 
patient  complained  that  men  came  to  her  room  nights,  carried 
her  away,  subjected  her  to  improper  and  indecent  treatment  and 
then  brought  her  back. 

A  more  common  motor  hallucination  is  the  verbal  motor 
hallucination.  Patients  who  complain  that  their  thoughts  are 
audible  may  be  brought  to  this  belief  by  feeling  their  lips  move 
as  in  speech,  and  inferring  that  they  are  involuntarily  speaking 
or  being  made  to  speak. 

Reflex  Hallucinations.  —  This  variety  of  hallucination  is 
based  upon  secondary  sensations  which  are  sensations  arising 
in  one  sensory  field  when  the  stimulus  has  been  applied  in 
another  sensory  field.  Thus  stimulation  of  the  eye  may  pro- 
duce sensations  of  sound,  stimulation  of  the  taste  bulbs  may 
produce  odors,  etc.,  etc.  The  following  cases  illustrate  these 
conditions : 

Mrs.  J.,  set.  25  years,  in  good  general  health,  complains  of 
naso-pharyngeal  catarrh  and  tickling  in  throat,  causing  cough. 
She  has  deflected  septum  and  enlarged  lingual  tonsils.  Opera- 
tion upon  these  and  subsequent  application  of  ordinary  styptics 
have  been  accompanied  by  the  odor  of  almonds  located  on  the 
side  of  the  nose. 

Mrs.  B.,  set.  28  years,  complains  of  having  a  bad  odor  in 
her  breath  which  seems  most  acute  to  her  in  her  nose.  Her 
friends  tell  her  that  they  cannot  detect  any  unpleasant  odor. 


42  OUTLINES    OF    PSYCHIATRY. 

She  seeks  special  medical  advice  because  she  appreciates  this 
odor  and  suspects  friends  of  being  too  courteous  to  tell  her  of 
it.  She  is  in  good  general  health  with  slight  hacking  cough 
and  tendency  to  clear  throat. 

Examination  shows  the  nose  to  be  in  normal  condition 
throughout,  the  nasal  vaults  are  unusually  accessible,  thus  leav- 
ing no  doubt  as  to  their  healthy  condition.  Pharynx  and 
larynx  normal. 

The  nostrils  were  alternately  plugged,  the  lips  closed  and 
air  from  each  nostril  and  the  mouth  tested  separately.  Not 
the  slightest  odor  could  be  detected,  though  she  appreciated  it 
herself  as  being  very  disagreeable.  Two  small  lingual  tonsils 
were  more  closely  examined  and  upon  the  posterior  side  of 
each  a  minute  morsel  of  food  was  found.  This  was  removed, 
but  on  examination  was  found  to  have  absolutely  no  odor.  It 
had  not  undergone  sufficient  change  to  disguise  its  character* 
— it  was  bread.  Shortly  after  its  removal  the  bad  odor  grew 
less.  Both  tonsils  were  at  once  removed  and  the  patient  sent 
home.  At  the  end  of  two  days  all  odor  had  disappeared.  At 
the  end  of  four  days  there  was  still  no  odor,  but  it  was  induced 
by  touching  the  neighborhood  of  the  tonsils  by  a  small  pledget 
of  cotton  carrying  a  weak  solution  of  citric  acid.  At  another 
time  it  was  induced  by  a  very  weak  faradic  current.  The  odor 
had  not  reappeared  at  the  end  of  six  weeks  except  by  stimu- 
lating the  taste  goblets,  and  the  patient  was  entirely  relieved 
of  the  hacking  cough. 

This  latter  case  was  truly  hallucinated  by  a  secondary  sen- 
sation, although  she  was  not  insane.  It  can  readily  be  seen, 
however,  how  such  a  phenomenon  occurring  in  a  predisposed 
individual  or  in  one  already  over  the  border  line  might  soon 
form  the  focus  of  well-marked  persecutory  delusions. 

The  phenomena  of  secondary  sensations,  the  so-called  sound 
photisms,  light  phonisms,  pain  photisms,  etc.,  have  been  known 
for  a  long  time  and  are  not  particularly  infrequent.  Bleuler 
and  Lehmann  found  them  present  in  one  form  or  another  in 
seventy-six  persons  out  of  a  total  of  five  hundred  and  ninety- 


GENERAL    SYMPTOMATOLOGY.  43 

six,  i.  e.,  twelve  and  one  half  per  cent.  In  most  all  of  these 
cases,  however,  that  have  come  to  my  attention,  the  primary 
and  secondary  perceptions  are  both  present  in  consciousness, 
and  the  patient  usually  has  not  serious  difficulty  in  distinguish- 
ing the  false  perception. 

The  following  case,  however,  will  illustrate  how  these  sec- 
ondary sensations  may  become  true  hallucinations : 

D.  C,  a  young  woman  admitted  to  the  hospital  with  an 
acute  psychosis  of  the  confusional  type  with  dream-like  hallu- 
cinations, both  visual  and  auditory.  She  saw  all  sorts  of 
visual  images,  processions  of  soldiers  and  the  like,  and  also 
heard  voices.  After  recovery  said  that  the  figures  she  saw 
were  in  motion  and  the  principal  direction  of  their  motion  was 
downward,  so  that  she  had  to  strain  to  keep  them  up  in  the 
visual  field;  also  saw  patches  of  light  which  moved  by  prefer- 
ence to  the  right. 

Examination  shows  vision  20-20  for  both  eyes,  with  slight 
astigmatism  and  slight  photophobia,  with  somewhat  abnormally 
red  retinal  reflex.  Septum  slightly  deflected  to  left  into  middle 
meatus.  Right  middle  turbinated,  is  bulbous  and  impmging 
on  septum.  There  is  a  sub-acute  catarrhal  naso-pharyngitis, 
probably  following  diphtheria,  which  she  has  had  three  times. 
Ears  show  slight  retraction  of  drum  membrane  with  slightly 
shortened  cone  of  light  in  each  side. 

Stimulation  of  the  retina  by  having  patient  look  at  light 
of  an  Argand  burner  produced  sound  as  of  ringing  bells,  which 
lasted  forty-two  seconds  after  the  light  was  turned  off  and 
eyes  shut.  In  trying  this  experiment  again  the  sound  devel- 
oped in  twenty-seven  seconds  after  the  stimulus  was  applied, 
and  had  ceased  in  twenty-two  seconds  after  it  was  withdrawn. 

In  this  case  the  motions  of  the  visions  would  indicate  that 
they  were  due  to  muscse  volitantes.  Particularly  is  this 
indicated  by  the  straining  effect  required  to  keep  the  images 
within  the  visual  field.  There  is  present,  however,  a  well- 
marked  catarrhal  condition  of  the  pharynx,  with  abnormalities 
of  the  septum  and  right  middle  turbinated  which  have  resulted 


44  OUTLINES    OF    PSYCHIATRY. 

in  a  moderate  grade  of  middle  ear  disease.  There  are  also 
present  on  experimentation  light  phonisms. 

The  sensory  falsifications  probably  took  their  origin  in  the 
extremely  sensitive  eye  from  the  misinterpretation  of  floating 
bodies  in  the  vitreous,  the  patient  seeing  these  bodies  against 
the  light  walls  and  ceiling  of  the  room  as  she  lay  upon  her 
back.  The  constant  stimulation  of  these  sensitive  eyes  brought 
about  the  light  phonisms  which  were  interpreted  as  voices,  the 
auditory  apparatus  being  in  an  especially  susceptible  state,  due 
to  the  summation  of  stimuli  from  the  abnormal  end  organ. 

Many  kinds  of  secondary  sensations  have  been  described, 
any  one  of  which  may  quite  possibly  give  rise  in  a  disordered 
mind  to  hallucinations,  thus  not  only  sound  photisms,  light 
phonisms  aiid  similar  combinations  in  the  regions  of  the  special 
senses  are  known,  but  the  more  obscure  region  of  the  coenes- 
thesis  is  sometimes  involved,  and  Gruber  has  described  colored 
temperature,  colored  movement,  colored  resistance,  movement 
hearing,  temperature  hearing,  resistance  hearing  and  many 
other  combinations  equally  complicated. 

Clouding  of  Consciousness. — The  process  of  perception,  as 
we  have  seen,  is  dependent  upon  sensations  coming  from  with- 
out, which,  however,  must  be  of  sufficient  strength  to  force 
their  way  into  consciousness  and  wake  up,  as  it  were,  the 
remains  of  former  sensations  with  which  they  become  asso- 
ciated. If  sensory  stimuli  have  not  this  strength  they  may  be 
said  to  be  inadequate.  We  are  constantly  beset  on  all  sides 
by  such  inadequate  stimuli.  The  presence  of  my  clothes  on 
the  different  parts  of  my  body  ordinarily  cause  no  appreciable 
sensations  and  thus  give  rise  to  no  perceptions.  The  many 
trifling  noises  going  on  about  me  while  I  am  absorbed  in 
writing  these  lines  is  not  heard.  The  strength  of  the  several 
sensory  stimuli  is  not  sufficient  to  cross  the  threshold  of  con- 
sciousness, their  threshold  value,  as  it  is  called,  is  too  low  to 
result  in  perception.  In  various  diseases  and  conditions  the 
threshold  value  of  sensations  is  greatly  altered.  This  is  very 
marked  in  certain  of  the  deliria,  for  example,  delirium  tremens. 


GENERAL   SYMPTOMATOLOGY.  45 

In  this  disease  we  find  the  patient  wholly  occupied  with  his 
terrifying  visions  and  quite  oblivious  to  the  outside  world  of 
realities.  Loud  sounds  fail  to  attract  his  attention,  the  nurse 
comes  and  goes  without  interrupting  the  course  of  his  delirium. 
Sensory  stimuli  of  ordinary  strength,  or  even  more  than  ordi- 
nary strength,  fail  to  cross  the  threshold  of  his  consciousness 
and  cause  perception.  If,  however,  the  patient  be  taken  firmly 
by  the  shoulders  and  held  or  even  mildly  shaken  while  a  ques- 
tion is  practically  yelled  at  him,  we  may  find  that  he  will  give 
a  perfectly  lucid  and  correct  answer.  The  strength  of  the  sen- 
sations has  been  sufficiently  increased,  the  resistance  has  been 
broken  down,  perception  takes  place. 

This  condition  of  clouding  of  consciousness  may  exist  in 
any  degree,  from  a  scarcely  noticeable  departure  from  clear 
consciousness  to  actual  coma,  and  as  we  can  readily  see  must 
be  the  cause  of  very  imperfect  perceptions  of  the  environment. 
Ordinary  stimuli  are  not  appreciated  at  all,  while  those  that 
have  sufficient  force  usually  only  give  rise  to  perceptions  for 
the  moment  and  are  never  adequately  assimilated.  Thus  we 
find  this  condition  prominently  in  evidence  in  the  various 
deliria,  where  it  is  usually  associated  with  disturbed  affects, 
disorders  of  the  train  of  thought,  and  hallucinations. 

This  can  perhaps  be  better  understood  if  we  will  study  some 
of  the  characteristics  of  consciousness  at  any  given  moment. 
At  such  a  moment  there  are  numerous  sensory  stimuli  which 
have  forced  themselves  over  the  threshold  of  consciousness, 
and,  as  it  were,  are  contending  for  supremacy — for  recogni- 
tion. All,  however,  cannot  be  equally  clearly  recognized,  so 
it  comes  that  one  arouses  clear  perception  while  the  others  are 
only  faintly  perceived.  While  I  am  writing  these  words  the 
word  I  am  at  the  moment  penning  is  perceived  clearly,  while 
the  other  words,  the  books  lying  about  me  on  the  table,  the 
striking  of  the  clock  in  the  adjoining  room,  and  many  other 
sensations  are  only  indefinitely,  hazily  perceived.  The  most 
clearly  perceived  sensory  stimuli  are  said  to  occupy  the  focal 
point  of  consciousness,  while  the  other  sensations  have  only  a 


46 


OUTLINES    OF    PSYCHIATRY. 


marginal  value.  This  can  be  better  understood  by  reference 
to  Fig.  3 — where  the  particular  moment  of  consciousness  is 
represented  by  a  wave — wave  of  consciousness.  The  apex  of 
the  wave  would  then  be  the  focal  point  of  clearest  perception, 
the  base  of  the  wave  the  threshold  of  consciousness  and  sensa- 
tions crossing  this  threshold  can  be  seen  to  have  any  degree  of 
clearness  as  they  approach  the  focal  point.  The  height  they 
reach  on  the  wave  would  then  be  a  measure  of  their  intensity 
for  that  particular  moment  of  consciousness. 


rOCAL 


THRESHOLD    OF    CONSCIOUSNESS 

Fig.  3.     A  wave  of  consciousness. 


Dream  States. — This  term  is  applied  to  certain  conditions 
because  of  the  resemblance  they  have  to  conditions  of  dream 
consciousness.  The  mind  is  occupied  by  numerous  dreamy 
ideas,  and  usually  also  by  multiform  hallucinations  which  may 
take  the  form  of  visions  producing  the  state  of  ecstasy.  Hal- 
lucinations often  occur  in  more  than  one  of  the  sensory  terri- 
tories contemporaneously,  but  when  this  is  the  case  they  har- 
monize and  are  consistent  with  one  another.  For  example,  the 
patient  who  is  terrified  at  the  flames  she  sees  near  her  bed, 
feels  also  their  heat.  Clouding  may  be  present,  the  threshold 
value  of  sensations  being  raised  so  that  no  impressions  of 
ordinary  strength  reach  consciousness,  the  result  being  that 
the  patient  may  be  quite  oblivious  of  his  surroundings.  Unlike 
the  normal  dream  state,  however,  psycho-motor  reactions  occur 
corresponding  to  the  content  of  consciousness. 


GENERAL    SYMPTOMATOLOGY.  47 

Disorientation. — Orientation  implies  the  correct  apprehend- 
ing of  the  environment,  and  one  is  said  to  be  fully  oriented 
when  they  understand  their  own  position  and  relation  with 
reference  to  the  different  aspects  of  their  environment.  These 
aspects  are  three,  viz :  temporal,  spatial  and  personal.  Tem- 
poral orientation,  then,  would  imply  correct  answers  to  such 
questions  as,  in  what  year  were  you  born?  what  year  is  this? 
what  day  is  this?  Spatial  orientation  would  imply  correct 
answers  to,  what  city  do  you  live  in?  on  what  street?  Per- 
sonal orientation  would  imply  a  correct  knowledge  of  who  the 
individuals  were  with  whom  the  patient  came  in  daily  contact, 
their  official  positions,  their  names,  etc.  Disorientation  is  the 
reverse  of  this  condition  and  implies  a  lack  of  apprehension  of 
these  three  aspects  of  the  environment  either  singly  or  together. 

Disorders  of  the  Content  of  Thought. 
Delusion. — A  delusion  is  a  false  belief,  but  as  such  is  not 
necessarily  evidence  of  insanity.  Many  false  beliefs  have  no 
pathological  significance  whatever.  A  man  may  believe  that 
to-day  is  Thursday  when  in  fact  it  is  Friday.  That  is  a  false 
belief  while  it  lasts,  but  has  only  the  significance  of  a  mistake. 
The  belief  of  certain  savages  that  dreams  represent  the  wan- 
derings of  their  disembodied  spirit  we  know  to  be  false  but 
not  an  evidence  of  mental  disease.  False  beliefs  or  delusions, 
then,  may  be  either  sane  or  insane,  and  it  is  for  us  to  endeavor 
to  distinguish  what  constitutes  a  belief  first  as  false  and  then, 
as  such,  what  characterizes  it  as  insane.  There  are  three  main 
characteristics  of  insane  delusions  in  general.  First :  they  are 
as  a  rule  very  evidently  not  true  to  facts,  highly  improbable, 
even  manifestly  impossible  often  to  the  extent  of  being  bizarre. 
Such,  for  instance,  are  the  delusions  of  great  wealth,  of  royal 
lineage,  and  those  of  a  certain  class  of  patients  who  believe 
that  they  have  no  stomach,  no  brains,  even  that  they  have  no 
head.  Second :  they  cannot  be  corrected  by  an  appeal  to  rea- 
son; not  originating  in  experience  they  cannot  be  corrected 
by  an  appeal  to  experience.     It  is  impossible  to  argue  the 


48  OUTLINES    OF    PSYCHIATRY. 

patient  out  of  his  insane  beliefs.  Third :  they  are  out  of  har- 
mony with  the  individual's  education  and  surroundings.  The 
sick  Fijian  lying  upon  his  back  and  cr^'ing  for  his  soul  to  come 
back  to  him  is  but  exemplifying  the  belief  of  the  race  that 
sickness  is  due  to  the  soul,  or  a  part  of  it,  leaving  the  body. 
Should  we  find  a  modern  American,  who  had  had  the  usual 
public  school  advantages,  acting  thus  we  would  be  justified  in 
supposing  him  unbalanced. 

It  sometimes  happens,  however,  that  a  false  belief  does  not 
show  any  of  these  characteristics  and  yet  may  be  an  insane 
delusion.  A  woman  who  says  her  husband  is  untrue  to  her 
has  not  voiced  a  belief  which  has  on  its  face  any  evidences  of 
impossibility,  and  with  no  knowledge  of  the  facts  it  cannot 
even  be  said  to  be  improbable,  and  while  not  susceptible  to  the 
test  by  argument,  it  is  certainly  not  out  of  harmony  with  the 
individual's  education  and  surroundings.  In  such  cases  it 
becomes  important  to  study  the  origin  of  the  belief,  to  find 
out  upon  what  sort  of  foundation  it  is  reared.  If  we  find  that 
it  resulted  from  the  patient  having  awakened  on  several  occa- 
sions during  the  night  and  found  her  husband's  legs  cold,  and 
having  reasoned  from  this  that  he  had  been  out  of  bed  to  keep 
an  appointment  with  his  paramour  in  an  adjoining  room  we 
will  at  once  have  no  difficulty  in  stamping  the  delusion  as 
insane  because  of  being  founded  upon  and  constructed  of  ideas 
which  do  not  logically  or  reasonably  lead  to  the  conclusions 
reached. 

Delusions  may  be  classified  for  our  purpose  into  ^xed  and 
changeable,  systematized  and  unsystematized. 

A  fixed  delusion  is  one  which  seems  to  be  firmly  imbedded 
in  the  mind  and  is  continuously  adhered  to  by  the  patient, 
while  changeable  delusions  are  constantly  changing  and  giving 
place  one  to  another. 

An  unsystematized  delusion  does  not  enter  into  organic  com- 
binations with  the  other  facts  of  consciousness,  but  stands  apart 
and  seems  not  to  have  been  assimilated.  While  it  may  be 
fixed,  it  exercises  no  special  control  over  the  patient's  conduct ; 


GENERAL   SYMPTOMATOLOGY.  49 

he  seems  to  rest  with  its  statement  alone  unable  to  substantiate 
his  position  by  cogent  argument  or  example.  A  patient  who 
believes  that  all  the  bones  in  his  body  are  broken,  but  never- 
theless goes  about  his  affairs  as  usual,  has  an  unsystematized 
delusion. 

A  systematized  delusion,  on  the  other  hand,  is  not  only 
assimilated  and  associated  with  the  other  facts  of  conscious 
experience  but  forms  a  motive  power  for  conduct.  It  is  sup- 
ported by  reasons,  by  arguments,  and  by  appeals  to  experience, 
it  is  acted  upon  as  if  it  were  an  actual  fact,  and  finally  it  may 
so  reach  out  its  influence  by  association  with  all  the  conscious 
experiences  of  the  individual  that  the  whole  life  of  the  patient 
is  centered  about  and  becomes  secondary  to  it.  The  patient 
with  a  systematized  delusion  of  persecution  regulates  his  whole 
life  in  order  to  avoid  his  persecutors.  The  food  is  carefully 
tasted  for  poison  and  perhaps  discarded,  the  bed  he  sleeps  in 
must  be  insulated  to  prevent  electric  currents  being  applied  to 
him  while  he  sleeps,  the  key-hole  and  all  cracks  stopped  up  so 
that  noxious  vapors  cannot  be  injected  through  them.  If  the 
patient  is  asked  for  an  explanation  of  this  conduct  he  is  ready 
with  interminable  reasons  and  appeals  to  experience  while  his 
arguments  are  woven  together  with  much  ingenuity  and  no 
little  logic.     His  delusion  is  systematized. 

A  further  classification  of  delusions  is  based  upon  Wer- 
nicke's classification  of  concepts.  It  is  a  very  valuable  and 
practical  one  from  a  clinical  standpoint.  Wernicke  classifies 
concepts  as  to  whether  they  relate  to  the  outside  world,  includ- 
ing other  persons ;  whether  they  relate  to  the  individual's  own 
personality,  or  whether  they  relate  to  the  individual's  own 
body  and  speaks  of  the  psychoses  which  involve  these  three 
orders  of  concepts  respectively  as  aUopsychoses,  autopsychoses, 
or  somatopsychoses.  A  patient  with  a  delusion  of  persecution 
would  be  suffering  from  a  disturbance  of  his  allopsychic  con- 
sciousness; if  he  had  a  delusion  that  he  had  committed  the 
unpardonable  sin  his  autopsychic  consciousness  would  be  in- 
volved, and  finally  if  he  believed  his  intestines  to  be  stopped 
5 


50  OUTLINES    OF    PSYCHIATRY. 

Up,  the  disorder  would  be  in  his  somatopsychic  consciousness. 
It  is  quite  possible,  even  common,  to  have  combinations  of 
these  varieties,  and  indeed  all  of  them  in  the  same  patient,  so 
the  patient  might  be  said  to  be  suffering  from  an  allo-auto- 
somatopsychosis. 

Hyper-quantivalent  Ideas. — In  speaking  of  ideas  we  use 
the  term  quantivaleiice  to  indicate  the  relative  value  which  the 
idea  has  in  the  consciousness  of  the  patient.  Under  ordinary 
circumstances  when  the  mind  is  functioning  normally  the  quan- 
tivalence  of  ideas  is  normal,  but  it  not  infrequently  happens 
that  owing  to  pathological  processes  or  abnormal  environment 
that  certain  ideas  attain  a  degree  of  importance  altogether  un- 
warranted. Under  such  circumstances  we  speak  of  the  ideas 
as  being  hyper-quantivalent.  This  condition  is  characterist- 
ically seen  in  morbid  suspicions,  delusions  of  a  persecutory 
character,  founded  upon  a  very  slight  basis  of  facts,  as  in  liti- 
gants or  soldiers  who  have  been  rebuked,  and  similar  conditions 
occurring  in  paranoid  states.  These  conditions  may  arise  upon, 
a  comparatively  normal  basis  in  persons  who  are  subjected 
to  abnormal  environmental  conditions,  particularly  conditions 
which  require  living  in  comparative  solitude  or  in  close  associa- 
tion with  a  few  people  to  the  exclusion  of  all  others.  These 
outward  conditions  are  often  seen  in  prisons  and  in  secluded 
army  posts. 

In  order  that  the  mind  may  continue  functioning  in  a  normal 
manner  it  is  necessary,  among  other  things,  that  its  contact 
with  an  environment  of  which  other  minds  form  a  part  should 
be  continuous  and  of  a  sufficiently  varied  character  to  keep  the 
process  of  idea  association  active  and  from  getting  into  grooves. 
Under  normal  circumstances  a  slighting  remark  made  to  an 
individual  is  perhaps  received  by  a  retort  in  the  same  vein  and 
the  normal  rush  of  ideas  which  an  active  life  necessitates  soon 
drowns  out  or  submerges  this  particular  idea,  so  that  it  has  not 
the  opportunity  to  constantly  recur  to  the  discomfort  of  the 
individual.  It  assumes  its  proper  relation  to  the  idea  content 
of  consciousness,  the  outward  facts  of  which  it  is  the  inner  rep- 


GENERAL    SYMPTOMATOLOGY.  $1 

resentation  are  seen  entirely  in  their  proper  perspective.  There 
has  been  no  distortion  of  the  normal  quantivalence  of  the  idea. 
Under  abnormal  environmental  conditions,  in  which  the  pa- 
tient leads  a  desultory  mental  life,  where  each  day  is  much  like 
the  preceding  and  there  is  little  variety  of  idea  association 
necessitated  by  daily  duties,  there  is  nothing  to  prevent  such 
an  idea  from  recurring  repeatedly  to  the  individual,  and  because 
of  this  recurrence,  and  because  it  occupies  so  frequently  the 
inner  consciousness,  the  outward  events  to  which  it  corre- 
sponds are  seen  in  a  distorted  perspective.  The  idea  has 
assumed  a  position  in  consciousness  totally  unwarranted  by  its 
real  importance.     It  has  become  hyper-quantivalent. 

Under  such  conditions  the  soldier  who  has  been  reprimanded 
broods  over  his  disgrace  until  what  was  in  reality  a  small  affair 
has  grown  by  constant  nursing  into  a  matter  of  tremendous 
importance :  the  veteran  who  has  been  denied  a  pension,  the 
litigant  who  has  lost  a  law  suit,  have  been  greatly  wronged 
and  cry  aloud  for  justice.  The  narrow-minded  malcontents 
who  see  life  from  a  distorted  and  intensely  personal  view-point 
are  the  favorable  subjects  for  the  development  of  hyper- 
quantivalent  ideas. 

Fixed  Ideas. — The  term  fixed  idea  is  usually  applied  to  these 
conditions  and  as  a  term  designates  them  vei-y  well.  The  fixed 
idea  must  be  hyper-quantivalent.  If  a  distinction  were  to  be 
made  it  might  be  made  on  the  basis  of  the  content  of  the  idea. 
Thus  hyper-quantivalence  is  usually  spoken  of  when  the  idea  has 
its  origin  in  the  allopsychic  consciousness.  The  litigant  pursuing 
case  after  case  to  obtain  his  rights,  or  the  discharged  employe 
making  repeated  appeals  for  investigation  are  examples.  The 
term  fixed  idea,  on  the  other  hand,  is  used  more  often  for  con- 
ditions arising  in  the  somatopsychic  or  autopsychic  field  of  con- 
sciousness. Thus  the  rather  timid  young  man  who  feels  his 
pulse  and  discovers  that  it  is  too  rapid  and  perhaps  somewhat 
irregular  acquires  as  a  result  a  fixed  idea  that  he  has  organic 
disease  of  the  heart.     The  woman  whose  husband  has  recently 


52  OUTLINES    OF    PSYCHIATRY. 

died  and  who  is  harassed  by  the  behef  that  he  might  have 
lived  had  she  given  him  a  certain  medicine  has  a  fixed  idea. 

In^both  of  these  conditions,  however,  the  patient  feels  the 
idea  to  be  the  outgrowth  or  reaction  of  his  normal  self  and 
not  in  any  way  abnormal  or  an  obtrusion  from  without  as  in 
the  cases  to  follow. 

Obsessions. — By  obsessions  we  mean  ideas,  emotions,  im- 
pulses, which  occupy  consciousness  persistently  and  irrespective 
of  the  desires  of  the  subject,  often  intruding  themselves  at 
inopportune  times  and  occupying  the  field  of  consciousness  to 
the  exclusion  of  other  ideas.  They  are  sometimes  spoken  of 
as  besetments,  as  they  come  unbidden  and  refuse  to  go  at  the 
will  of  the  subject.  They  exist  with  clear  consciousness  and 
are  often  fully  comprehended  by  the  patient  at  their  true  value. 

In  the  mild  forms  they  are  quite  common  and  occur  not 
infrequently  in  normal  persons,  usually  as  a  result  of  fatigue. 
We  are  all  familiar  with  the  phenomena  of  the  constant  recur- 
rence to  the  mind  of  a  tune  that  was  heard  the  night  before  at 
the  opera,  it  invades  consciousness  to  the  extent  of  actually 
interfering  with  the  transactions  of  the  usual  business  of  the 
day.  Then  there  is  the  somewhat  more  aggravated  case  of 
the  person  who  goes  to  bed  but  is  worried  for  fear  he  may  not 
have  turned  the  gas-cock  quite  shut;  he  tries  to  banish  the 
idea,  turns  over  to  go  to  sleep  but  it  will  not  go  and  finally  in 
sheer  desperation  he  gets  up,  and,  satisfying  himself  that  the 
gas  is  actually  turned  off,  returns  to  bed  and  goes  to  sleep. 

The  commonest  and  best  known  of  the  obsessions  are  the 
so-called  phobias  or  fears.  These  fears  are  usually  very  spe- 
cific, referring  to  some  special  class  of  objects  or  set  of  con- 
ditions and  receive  names  accordingly.  Thus  we  have  viiso- 
pJiobia  (fear  of  dirt)  ;  victallophobia  (fear  of  metal,  such  as 
door  knobs,  money,  etc.)  ;  agoraphobia  (fear  of  wide  or  open 
spaces)  ;  claustrophobia  (fear  of  narrow  or  closed  spaces)  ; 
pyrophobia  (fear  of  fire)  ;  and  so  on  indefinitely.  Patients 
suffering  from  these  obsessions  are  often  completely  dominated 
by  them  under  conditions  that  call  them  into  existence.     The 


GENERAL   SYMPTOMATOLOGY.  53 

patient  with  agoraphobia  crosses  the  street  in  fear  and  trem- 
bHng,  or  perhaps  cannot  summon  sufficient  courage  to  cross  it 
at  all  unless  some  one  is  with  him,  while  on  the  contrary  the 
claustrophobiac  cannot  endure  a  small  or  closed  room,  but  must 
have  the  doors  open,  or  if  in  a  crowded  hall  is  suddenly  seized 
with  fear  and  forced  to  make  a  hasty  exit. 

Of  not  infrequent  occurrence  also  are  the  obsessions  of 
doubt.  These  doubts  may  arise  about  anything,  even  the  sim- 
plest acts  of  every-day  life.  A  patient  upon  retiring  may  be 
seized  with  a  doubt  as  to  whether  he  turned  the  gas  off  or 
locked  the  door  in  the  main  hall,  and  is  forced  to  get  up  and 
go  and  see,  only  to  be  seized  again  by  the  same  doubt  when 
he  returns  to  bed;  another,  having  written  several  letters,  is 
forced  to  open  all  of  them  to  make  sure  that  the  right  ones 
are  in  each  envelope.  Still  others  have  doubts  about  religious 
or  metaphysical  matters.  So  we  have  doubters  who  question 
the  problem  of  a  future  life  or  the  existence  of  things  as  they 
appear  to  the  senses,  etc. 

If  the  actions  which  the  obsessions  tend  to  initiate  are  re- 
sisted the  tendency  becomes  more  and  more  imperative  until 
yielding  is  forced  and  finally  these  patients,  although  fully 
understanding  their  condition  and  the  abnormality  of  their 
ideas,  may  pass  their  lives  in  a  continual  round  of  actions  made 
necessary  by  their  obsessions. 

Because  of  this  element  in  the  obsessed  state  that  impels  to 
action  these  conditions  are  often  spoken  of  as  imperative  ideas 
or  imperative  concepts. 

Autochthonous  Ideas. — These  ideas  come  into  the  patient's 
mind  like  foreign  bodies,  as  it  were,  and  not  as  a  result  of  the 
usual  methods  of  association.  The  patient  feels  that  he  has 
strange  thoughts,  thoughts  that  are  not  his  thoughts  and  usually 
interprets  their  occurrence  as  being  due  to  outside,  usually 
malevolent,  influences.  The  thoughts  are  forced  on  him  by 
hypnotism,  thought  transference,  by  his  enemies.  Bad  thoughts 
are  thus  placed  in  his  mind  and  often  he  is  forced  to  act  as  a 
result  of  them  although  he  does  not  want  to  and  proclaims 
that  it  is  all  against  his  will. 


54  outlines  of  psychiatry. 

Disorders  of  the  Train  of  Thought. 
Flight  of  Ideas. — In  the  normal  process  of  thinking  our 
thoughts  are  directed  consistently  to  a  well-defined  end — the 
goal  idea — and  all  other  ideas  fall  into  a  subordinate  position 
until  this  is  attained.     In  flight  of  ideas  the  patient  either  has 
no  goal  idea  or  else  at  once  loses  it  so  that  there  is  no  consistent 
effort  directed  towards  attaining  it,  and  the  thought  therefore 
wanders  here  and  there  under  the  influence  of  chance  associa- 
tions.    As  a  result  the  train  of  thought  instead  of  progressing 
changes  direction  frequently,  returns  upon  itself,  and  never 
reaches  any  logical  end.     The  various  ideas  are  not,  however, 
incoherent — they  do  not  fail  to  be  connected  one  with  another, 
ahhough  it  may  be  quite  impossible  at  times  to  see  just  what 
their  connection  is.     If  the  associations  are  external,  that  is, 
originate  in  the  surroundings,  it  is  usually  quite  possible  to 
place  them ;  when,  however,  they  are  internal,  that  is,  originate 
in  the  patient's  mind,  it  may  be  quite  impossible  to  conceive 
what  they  may  be.     An  example  will  illustrate  these  various 
conditions :  "  Do  you  know  I  was  kidnapped  to  be  sent  here 
twice.     I  saw  a  mock  funeral  of  me  before  I  left  home.     This 
was  done  because  I  am  a  great  inventor.     The  Pope  of  Rome 
is  the  greatest  human  being  in  the  universe.     He  is  the  head 
of  the  Catholic  Church.     My  head  (association  of  the  word 
head  in  two  different  meanings)  is  good  and  sound,  and  I  am 
certainly  not  insane.     Do  you  hear  that  ticking  of  the  clock? 
(External  association.)     It  says,  'call  the  little  heifer,  the 
heifer  is  sick.'     Did  you  ever  see  the  gloves  veterinary  sur- 
geons use  when  they  doctor  sick  cows  ?     ( Internal  association. ) 
How  would  you  like  to  be  a  veterinary  surgeon  ?     Say !  what 
are  you  keeping  me  here  for  anyhow?     I  want  to  go  home. 
(Here  he  was  asked  how  he  slept  at  night.)      I  have  slept 
excellently ;  that  is  because  I  am  of  such  a  strong  constitution. 
The  constitution  of  the  United  States   (association  as  above 
with  the  word  head — probably  the  association  is  in  large  part 
at  least  a  sound  or — as  it  is  called — a  clang  association)  was 
signed  by  Thomas  Jefferson.     He  was  just  a  man,  but  he  was 


GENERAL    SYMPTOMATOLOGY.  55 

not  the  inventor  I  am."  While  there  are  many  places  in  the 
example  where  the  connecting  link  is  missing — probably  be- 
cause it  was  an  association  formed  entirely  within  the  patient's 
mind — still  the  connection  can  be  made  out  in  a  sufficient 
number  of  instances  to  establish  the  characteristics  of  the  train 
of  thought.  One  of  the  principal  characteristics  of  this  type 
of  the  train  of  thought  is  its  great  liability  to  change  of  direc- 
tion by  external  association,  as  for  example,  the  ticking  of  the 
clock  in  the  above  stenogram.  This  quality  is  known  as  dis- 
tractibility.  Any  sensory  impression  is  liable  to  be  the  starting 
point  of  idea-association,  so  that  these  patients'  train  of  thought 
may  be  turned  at  will,  almost,  by  such  devices  as  shaking  a 
bunch  of  keys  before  them,  saying  some  word  loudly,  showing 
them  a  newspaper,  or  in  other  words,  momentarily  distracting 
their  attention. 

This  condition  of  flight  of  ideas  outwardly  appears  to  be 
an  expression  of  an  increased  rapidity  of  the  flow  of  idea- 
association.  However,  this  is  not  so,  as  an  example  will  illus- 
trate. The  low  C  tuning-fork  used  in  testing  hearing  vibrates 
128  times  per  second.  If  the  amplitude  of  vibration  which, 
although  it  is  readily  appreciable,  is  only  a  small  fraction  of 
an  inch,  be  multiplied  by  128  the  resulting  distance  would  be 
but  a  few  inches  at  most.  Let  the  fork  be  moved  this  distance 
in  one  second's  time  and  the  motion  will  be  seen  to  be  not  fast 
by  any  means  but  slow.  So  in  flight  of  ideas  if  the  rapidity 
of  movement  in  a  given  direction  by  idea-association  be  tested, 
the  release  of  ideas  will  be  found  to  be  slow.  Like  the  tuning- 
fork,  however,  there  occurs  a  rapid  change  of  direction. 

Tests  of  reaction  time  in  this  condition  show  that  it  is  abnor- 
mally slow  and  this  can  be  readily  elicited  by  giving  the 
patient  a  word  such  as  cat,  fur,  glass,  or  similar  simple  words, 
and  asking  him  to  write  down  as  rapidly  as  he  can  either  all 
words  he  can  think  of  rhyming  with  the  key-word  or  all  words 
that  come  to  his  mind  in  association  with  it.  The  slowness 
with  which  these  tests  are  executed  and  the  meagerness  of  the 
result  will  be  in  marked  contrast  to  the  apparent  wealth  of  ideas 
and  facility  of  their  association  and  release. 


56  OUTLINES    OF    PSYCHIATRY. 

Circumstantiality. — Circumstantiality,  although  sometimes 
superficially  resembling  flight  of  ideas,  is  quite  different  from 
it  in  its  completely  developed  form.  Although  there  is  a  fre- 
quent change  of  direction  of  the  train  of  thought  the  goal  idea 
is  maintained  and  ultimately  reached,  and  although  there  are 
numerous  digressions  as  each  circumstance  in  the  narrative  is 
elaborated  and  explained  the  original  pathway  is  returned  to 
and  the  general  direction  maintained.  Thus  a  patient  in  telling 
about  a  cane  in  her  possession  upon  which  a  ribbon  is  tied  for 
ornament  must  tell  how  she  came  to  have  the  idea  of  decorating 
the  cane,  who  else  in  the  nighborhood  had  such  a  cane  deco- 
rated, what  they  had  said  to  her  and  she  to  them  about  it,  how 
she  had  taken  the  ribbon  off  and  now  had  put  it  in  two  boxes 
in  the  house,  how  the  ribbons  had  become  faded,  where  she 
got  the  boxes,  who  gave  them  to  her,  and  what  their  color  was. 
All  these  details  must  be  entered  into  before  she  can  proceed 
with  the  thread  of  her  narrative. 

This  condition  is  often  found  in  a  moderately  developed 
form  in  women  and  has  no  special  significance  other  than 
showing  a  lack  of  appreciation  of  the  relative  values  of  ideas. 
In  the  senile,  where  there  is  some  mental  impairment,  the  goal 
idea  may  be  quite  lost  sight  of  in  the  mass  of  detail  and  the 
resemblance  to  flight  is  then  much  more  marked,  still  there  is 
a  more  marked  tendency  to  maintain  the  general  direction  of 
the  train  of  thought. 

Retardation. — Retardation,  difficulty  of  thinking,  as  it  is 
often  called  to  distinguish  it  from  psychomotor  retardation, 
shortly  to  be  described,  is  a  decided  slowness  in  the  elaboration 
of  ideas,  the  patient's  stock  of  ideas  do  not  seem  to  be  available 
or  accessible,  ideas  come  slowly  to  the  mind,  there  is  great 
difficulty  in  forming  judgments,  in  coming  to  conclusions,  in 
reaching  decisions  which  is  felt  by  the  patient  as  an  inadequacy 
in  dealing  with  mental  problems.  This  condition  is  expressed 
by  the  patient  in  great  slowness  of  speech,  a  long  interval 
elapsing  before  an  answer  is  given  to  a  question  or  something 
done  as  requested  {initial  retardation) ,  and  when  the  question 


GENERAL   SYMPTOMATOLOGY.  57 

is  answered  or  the  act  done  it  is  done  very  slowly  and  delib- 
erately (executive  retardation). 

If  such  a  patient  be  asked  to  count  from  one  to  twenty,  be- 
ginning at  a  given  signal  and  counting  as  fast  as  possible,  it 
may  be  several  seconds  before  he  starts,  and  while  a  normal 
person  should  do  this  in  two  or  three  seconds,  he  may  take 
often  twenty,  thirty,  or  even  never  finish  at  all. 

Paralysis  of  Thought. — A  complete  absence  of  all  internally 
initiated  conscious  processes.  Impressions  from  without  are 
not  assimilated,  form  no  associations,  leave  no  traces.  Mental 
life  is  in  abeyance  or  abolished. 

Disorders  of  Volition  (Will), 
Decreased  Psychomotor  Activity. — This  symptom  corre- 
sponds in  the  motor  sphere  to  difficulty  of  thinking  in  the 
psychic  sphere.  Whereas  in  difficulty  of  thinking  we  might 
say  that  there  was  a  slowness  in  the  liberation  of  ideas  in  psy- 
chomotor retardation,  we  can  say  there  is  a  slowness  in  the 
liberation  of  voluntary  motor  impulses.  The  patient's  move- 
ments are  slow  and  deliberate,  and  we  find  here  the  same  dis- 
tinction of  initial  and  executive  retardation.  This  is  a  promi- 
nent symptom  of  depressive  melancholia. 

Increased  Psychomotor  Activity. — This  is  just  the  oppo- 
site of  the  above  condition,  and  is  due  to  an  abnormally  facile 
release  of  voluntary  motor  impulses.  It  manifests  itself  in 
great  restlessness,  constant  activity,  even  to  the  point  of  vio- 
lence and  destructiveness,  and,  like  flight  of  ideas,  the  various 
acts  are  not  consistently  directed  to  a  definite  goal  but  to  this 
and  that  end  under  the  influence  of  chance  associations.  This 
is  a  prominent  symptom  of  mania. 

Impulsions. — Impulsions  or  impulses  are  tendencies  to  act 
which  are  more  or  less  uncontrollable,  often  absolutely  so. 
The  act  may  be  of  any  kind  and  in  this  class  belong  the  so- 
called  wanm,  such  as  ^/^/>foinafn'a  (a  morbid  impulse  to  steal), 
pyromania  (a  morbid  impulse  to  set  things  on  fire),  dipso- 
mania  (an  impulse  to  drink),  etc.     These  impulses  appear 


58  OUTLINES    OF    PSYCHIATRY. 

without  cause,  the  patient  is  restless  until  they  are  carried  out, 
and  their  accomplishment  is  accompanied  by  a  feeling  of  relief. 

Compulsions. — Closely  allied  to  the  impulses  are  the  so- 
called  compulsions.  The  compulsions,  like  the  obsessions, 
already  described,  are  felt  by  the  patient  to  be  pathological,  to 
be  forced  upon  him,  as  it  were.  The  impulse  of  the  dipso- 
maniac, like  the  fixed  idea,  is  conceived  by  the  patient  as  origi- 
nating within  and  being  a  part  of  him,  a  natural  development 
of  his  character,  perhaps,  while  the  compulsion  is  often  directed 
to  the  doing  of  some  act  distinctly  abhorrent  to  the  patient, 
such,  for  instance,  as  murder,  and  he  may  take  elaborate  pre- 
cautions to  protect  others  or  even  have  himself  locked  up  to 
insure  against  its  possibility. 

If  these  compulsions  are  resisted  or  interfered  with  they 
give  rise  to  certain  symptoms  which  in  marked  cases  constitute 
a  veritable  crisis.  The  patient  feels  weak,  trembles,  becomes 
dizzy,  perspires,  and  finally  yields  to  find  that  at  once  all  these 
symptoms  disappear. 

Stereotypy. — In  stereotypy  the  voluntary  impulse  once  set 
in  motion  tends  to  continue  or  repeat  itself  in  the  same  way 
indefinitely,  thus  we  have  three  forms  of  stereotypy,  viz., 
stereotypy  of  attitude,  of  movement,  and  of  speech. 

In  stereotypy  of  attitude  the  patient  tends  to  maintain  a  par- 
ticular, usually  peculiar,  position,  such  as  standing  in  the  cor- 
ner, one  arm  raised,  lying  on  the  bed  with  the  head  hanging 
over  the  side.  The  muscles  are  usually  tense  and  the  patient 
resists  attempts  to  alter  his  position. 

Stereotypy  of  movement  manifests  itself  in  the  continuous 
repetition  of  some  movement,  usually  meaningless,  such  as 
swaying  back  and  forth,  nodding,  wrinkling  the  forehead  or 
the  like.  When  the  word  stereotypy  is  used  without  qualifi- 
cation this  variety  is  referred  to.  When  these  peculiarities  are 
constant  and  characteristic  of  the  patient,  particularly  if  they 
occur  in  connection  with  his  ordinary  conduct,  such  as  pecu- 
liarities of  walking,  eating  at  table,  or  in  speaking,  they  are 
usually  spoken  of  as  mannerisms. 


GENERAL   SYMPTOMATOLOGY.  59 

Stereotypy  of  speech  shows  itself  in  the  constant  repetition 
of  the  same,  usually  senseless,  phrases,  and  is  more  commonly 
known  as  verbigeration. 

The  persistence  of  a  motor  impulse,  whether  in  action,  speech 
or  writing,  and  commonly  expressing  itself  by  the  iteration  and 
reiteration  of  the  same  word  or  phrase,  generally  in  an  attempt 
to  answer  a  question,  is  called  perseveration.  It  may  not  be 
at  all  senseless,  but  simply  show  the  tendency  of  a  motor 
impulse  once  generated  to  hold  the  field,  as  in  the  following 
letter  written  to  me  by  a  young  epileptic. 

"May  2 1  St,  1907.  Supt.  Wm.  A.  White  I  would  like  to 
have  a  talk  with  you  about  matters  my  papa  advise  me  to  do. 
How  can  I  get  to  see  you?  will  you  come  to  see  me  or  can  I 
come  to  see  you?  I  would  like  very  much  to  see  you  Supt. 
Wm.  A.  White  I  am  well  but  I  want  to  see  you  so  I  can  have 
a  talk  with  you  about  matters  that  my  papa  advise  me  to  do  I 
am  feeling  all  right  now  than  I  did  some  years  ago  but  I 
would  like  to  see  you  and  have  a  talk  with  you  about  matters 
that  my  Papa  advise  me  to  do  and  I  would  be  very  thankful  to 
you  Supt.  Wm.  A,  White  if  I  could  get  to  see  you  please  do 
it  for  me  so  I  can  have  a  Talk  with  you  about  matters  my  papa 
advised  me  to  do." 

Negativism. — Negativism  is  a  peculiar  condition  which  is 
manifested  by  the  patient  doing  exactly  the  opposite  of  what  he 
is  requested  to  do.  Every  attempt  to  get  the  patient  to  do 
anything  results  in  the  release  of  a  motor  impulse  the  exact 
opposite  of  that  required  for  the  performance  of  the  act. 

Patients  exhibiting  this  symptom  not  only  do  the  opposite 
of  what  is  requested  of  them  but  exhibit  negativistic  tenden- 
cies toward  the  promptings  of  normal  desires.  They  do  not 
yield  to  the  inclination  to  empty  the  bladder  or  rectum,  so  that 
these  organs  often  become  overloaded  with  disastrous  results. 
They  often  also  permit  saliva  to  accumulate  in  large  quantities 
in  the  mouth,  even  until  it  has  undergone  putrefactive  changes. 

When  negativism  manifests  itself  in  inactivity,  as  in  the 
above  examples,  it  may  be  said  to  be  passive.     Often,  however, 


60  OUTLINES    OF    PSYCHIATRY. 

it  is  active,  the  patient  actively  resisting  attempts  to  induce  him 
to  move,  eat.  or  dress, — he  is  said  then  to  be  resistive. 

Suggestibility. — Suggestibility  may  be  said  to  be  the  exact 
opposite  of  negativism.  The  patient's  reactions  are  determined 
by  impressions  or  suggestions  derived  from  others.  It  is 
manifested  in  various  ways.  In  extreme  cases  the  patient 
resembles  a  lay  figure ;  the  limbs  can  be  placed  in  any  position 
and  are  there  retained  indefinitely.  This  condition  is  desig- 
nated as  catalepsy,  or  flexibilitas  cerea  (waxy  flexibility). 
Often  suggestibility  is  manifested  by  the  patient  repeating 
words  or  phrases  said  in  his  presence — echolalia — or  actions 
done  before  him,  such  as  taking  out  the  watch,  putting  the 
hands  to  the  face — echopraxia.  This  method  of  reaction  in 
which  personal  initiative  seems  to  be  absolutely  in  abeyance  is 
often  spoken  of  as  automatic — the  symptom  is  known  as  auto- 
matism. When  the  automatic  responses  are  to  commands  then 
the  term  coinuiand  autoniatisui  is  used. 

Stupor. — Stupor  is  a  condition  in  which  there  is  usually  a 
profound  disturbance  of  consciousness,  but  the  feature  which 
gives  it  its  distinctive  outward  character  is  psychomotor  inhi- 
bition— voluntary  motion  is  to  a  greater  or  less  extent  in  abey- 
ance. The  mental  state  in  the  different  varieties  of  stupor 
differs  greatly  from  profound  clouding  of  consciousness  to 
almost  clear  consciousness,  as  in  the  catatonic  stupor  of  demen- 
tia precox.  To  this  latter  condition,  in  which  the  patient, 
although  quite  immobile,  is  still  fully  alive  to  what  is  going 
on  about  him,  the  term  pseudo-stupor  has  been  given. 

Disorders  of  the  Emotions. 
Exaltation. — Exaltation  is  a  condition  of  morbid  emotional 
elation,  a  feeling  of  happiness  and  well-being  not  warranted 
by  the  condition  of  the  patient  or  his  surroundings.  It  is  one 
of  the  most  prominent  symptoms  of  mania,  and  is  here  com- 
bined with  increased  psychomotor  activity.  With  exaltation 
is  often  associated  a  marked  degree  of  irritability  with  some- 
times outbursts  of  angry  states. 


GENERAL    SYMPTOMATOLOGY.  6 1 

Depression. — Depression  is  the  opposite  of  exaltation.  It 
it  a  morbid  feeling  of  unhappiness  not  warranted  by  the  con- 
dition of  the  patient  or  his  surroundings.  It  is  one  of  the  most 
prominent  symptoms  of  melancholia,  and  in  that  variety  known 
as  affective  or  involution  melancholia  often  gives  rise  to  a  state 
of  anxiety  with  marked  precordial  distress,  difficulty  of  breath- 
ing, and  some  motor  agitation. 

Emotional  Deterioration. — A  condition  of  poverty  of  the 
emotions  manifesting  itself  by  indifference  and  occurring  in 
conditions  of  mental  deterioration,  particularly  seen  in  demen- 
tia precox,  paresis  and  senility. 

Morbid  Anger. — This  symptom,  except  as  due  to  transient 
conditions  of  irritability,  as  in  mania,  is  seen  most  often  in 
the  defective.  It  is  often  a  marked  feature  in  idiots  and 
imbeciles,  constituting  them  very  dangerous  patients,  but  is 
also  seen  among  the  higher  defectives,  the  morally  deficient, 
and  is  here  often  combined  with  great  cruelty. 

Disorders  of  Memory. 

Amnesia. — Amnesia  is  loss  of  memory.  The  loss  may  be 
circumscribed — only  for  certain  things  or  extending  over  a 
very  definite  space  of  time — or  it  may  be  more  general.  Loss 
of  memory  extending  over  definite  periods  of  time  is  usually 
the  result  of  illness  or  injury.  In  such  cases  the  amnesia 
usually  has  a  fairly  definite  beginning  with  the  delirium  of  the 
illness  or  the  occurrence  of  the  injury  and  usually  also  a  fairly 
definite  ending.  It  is  known  as  retrograde  amnesia.  If,  on 
the  contrary,  the  amnesia  is  continuous,  the  patient  seems  to 
be  no  longer  able  to  store  up  memories,  as  is  so  typically  seen 
in  the  senile,  the  amnesia  is  anterograde  amnesia. 

Hypermnesia. — An  exaggerated  degree  of  retentiveness, 
often  seen  in  the  remarkable  memory  for  details,  in  some  cases 
of  chronic  delusional  insanity,  who  seem  to  remember  every 
detail  in  their  lives  as  bearing  on  their  delusional  system. 

Paramnesia. — This  is  a  disorder  of  memory  in  which  events 
are  remembered  which  never  happened.     An  example  of  this 


62  OUTLINES    OF    PSYCHIATRY. 

was  afforded  by  a  patient  who  stopped  me  while  I  was  going 
through  the  ward  and  told  me  that,  while  she  was  dining  in 
another  ward,  I  had  entered  the  dining-room  and  informed  her 
that  any  time  her  satchel  was  ready  she  could  go.  As  a  matter 
of  fact,  I  had  not  even  seen  the  patient  upon  the  occasion  she 
referred  to.  When  these  false  memories  are  projected  into 
the  past  and  associated  with  delusions,  often  of  an  explanatory 
nature,  as  occurs  in  paranoia,  the  symptom  is  known  as  retro- 
spective fahHication  of  mcuiory. 

Disorders  of  Attention. 

Aprosexia. — This  is  the  condition  of  inability  to  fix  the 
attention  for  any  length  of  time  in  one  direction  and  is  seen 
typically  in  mania.  Here  the  attention  wanders  rapidly  from 
one  thing  to  another  and  as  a  result  perception  is  inadequate. 
The  different  elements  of  the  environment  are  not  attended  to 
sufficiently  to  insure  their  correct  perception.  This  insuffi- 
ciency of  perception  gives  rise  to  the  maniac's  defects  of  orien- 
tation most  frequently  seen  with  respect  to  persons,  some  slight 
resemblance  being  hit  upon  and  the  person  mistaken  for  some- 
one else,  a  former  acquaintance  or  associate. 

Enfeeblement  of  the  power  of  voluntary  attention  is  one  of 
the  most  characteristic  of  the  signs  of  dementia  and  is  a  promi- 
nent symptom  in  the  various  dementing  psychoses,  for  exam- 
ple, in  dementia  precox. 

Hyperprosexia. — In  this  condition  the  attention  of  the  pa- 
tient is  completely  absorbed  by  some  thoughts,  usually  by  his 
delusions.  This  complete  absorption  also  gives  rise  to  disor- 
ders of  perception,  as  the  environment  is  not  attended  to  and 
often  not  perceived  at  all.  The  condition  may  give  rise  to 
actual  delusions.  A  young  woman,  who  was  suffering  from 
the  most  profound  melancholia  with  painful  delusions,  was  so 
absorbed  in  these  that  she  did  not  perceive  the  tray  of  food 
that  was  brought  to  her  and  subsequently  when  it  was  brought 
to  her  notice  thought  some  mysterious  power  must  be  respon- 
sible for  its  presence. 


general  symptomatology.  63 

Disorders  of  Personality. 

To  understand  these  disorders  we  must  understand  what  con- 
stitutes personaHty.  The  individual,  besides  receiving  certain 
information  from  the  environment  and  forming  certain  ideas, 
has  beyond  this  a  consciousness  of  self,  a  feeling  that  all  his 
perceptions  and  ideas  are  experiences  of  a  single  self,  a  self 
that  maintains  its  own  individual  identity  throughout,  and 
which  the  individual  calls  "  I."  This  problem  of  self-con- 
sciousness, although  the  riddle  of  psychology,  presents  certain  i' 
features  useful  in  elucidating  the  problem  in  hand. 

Our  consciousness,  as  we  know  it,  is  subject  to  many  inter- 
ruptions, many  lapses,  so  that  in  an  ordinary  lifetime  hiatuses 
appear  in  its  course,  yet  the  notion  of  personal  identity  is  not 
thereby  destroyed.  For  example,  every  profound  sleep  de- 
stroys the  continuity  of  consciousness.  We  may  conceive, 
however,  that  underlying  all  these  manifestations,  such  as  dis- 
appear from  view  in  the  profundity  of  sleep,  there  are  certain 
permanent  features  which  form  the  foundation,  the  continuum 
of  consciousness  upon  which  the  transitory  features  as  we 
see  them  are  erected  as  epiphenomena.  The  most  important 
element  in  this  fundamental  continuum  is  the  cocncsthcsis — 
made  up  of  what  we  must  conceive  as  a  continuous  flow  of 
sensations  from  all  the  organs  of  the  body  to  the  mind.  This 
flow  of  sensations  is  constant  throughout  life,  and  in  the 
absence  of  disease  varies  little  either  as  to  quality  or  intensity. 
It  is  the  continuous,  ever  present  element  of  our  consciousness. 
The  other  elements,  of  which  we  have  directly  a  better  knowl- 
edge, made  up  for  the  most  part  of  perceptions  of  the  outer 
world  of  reality,  vary  much  more  in  correspondence  to  many 
factors,  particularly  as  to  the  nature  of  the  environment,  and 
the  characteristics  of  the  perceiving  mind  as  the  result  of  past 
experiences.  It  is  these  two  elements  of  consciousness  which 
make  up  the  personality. 

Transformation  of  the  Personality. — This  phenomenon  is 
seen  in  the  paranoid  conditions  typically,  that  gradual  growth 


64  OUTLINES    OF    PSYCHIATRY. 

of  a  delusional  system  accompanied  and  probably  to  some  ex- 
tent dependent  upon  disorders  in  the  realm  of  the  organic  sen- 
sations. The  paranoiac,  with  his  profound  disturbance  of  allo- 
psychic consciousness,  sees  the  outer  world  of  reality  twisted, 
deformed,  as  though  he  were  viewing  it  through  an  astigmatic 
medium.  All  the  facts  of  his  life,  his  knowledge  of  the  world 
are  distorted  to  conform  to  the  deformity  of  the  medium 
through  which  he  views  them.  Not  only  are  these  elements 
of  his  personality  seriously  disordered,  but  its  very  foundation 
— the  ccenesthesis — is  also  seriously  disturbed,  as  seen  particu- 
larly in  the  first  stage  of  the  disease.  All  of  the  elements  that 
go  to  make  up  the  patient's  personality  being  so  completely  dis- 
ordered, the  expressions  of  that  personality  are  similarly  disor- 
dered and  we  have  the  picture  of  the  third  stage,  the  final  result 
of  the  disease  process  in  its  natural  unfolding — transformation 
of  the  personality. 

Depersonalization. — A  lesser  degree  of  the  same  sort  of 
process  results  in  a  disorganization,  a  breaking  up  of  the  per- 
sonality. This  is  seen  in  many  conditions  and  is  associated 
with  a  feeling  of  unreality,  and  occurs  as  a  part  of  the  delirimn 
of  negation.  The  patients  proclaim  that  they  are  changed, 
they  are  not  themselves.  One  of  my  patients  would  look  in 
the  glass  and  stare  in  wonder  at  her  reflection,  saying  her  eyes 
were  not  hers,  they  were  cat's  eyes.  Another  patient  affirmed 
she  had  no  head,  no  arms,  no  body,  no  mind,  nothing.  The 
feeling  of  personal  identity  in  these  cases  has  become  disrupted, 
the  personality  disorganized. 

Multiple  Personality. — In  this  condition  the  patient  passes 
through  stages  in  each  of  which  the  personality  is  different. 
The  usual  cases  are  those  in  which  a  secondary  personality 
grows  up  in  the  individual  and  at  times  overwhelms  the  normal 
personality  and  occupies  the  stage  to  its  exclusion.  These  are 
the  cases  of  so-called  double  consciousness.  The  two,  or  some- 
times more,  personalities  are  usually  separated  from  each  other 
by  complete  amnesia,  so  that  one  does  not  know  of  the  exist- 
ence of  the  other. 


CHAPTER  VII. 
EXAMINATION  OF  THE  INSANE. 

In  no  department  of  medicine  is  a  complete  examination  of 
the  patient  more  important  than  in  the  department  of  psy- 
chiatry. This  examination  must  not  only  include  the  symp- 
toms that  the  patient  may  present  when  seen,  but  must  also 
include  the  most  detailed  obtainable  anamnesis.  It  must  be 
borne  in  mind  that  insanity  is  a  condition  of  an  individual  who 
was  previously  sane  and  that  above  all  it  is  not  a  something 
that  comes  from  without,  attacks  and  seizes  on  the  patient  like, 
for  example,  a  pathogenic  microorganism,  but  is  rather  to  be 
considered  as  a  type  of  reaction  of  the  individual  to  certain 
inimical  conditions.  In  order,  therefore,  to  understand  a  par- 
ticular case  it  is  of  the  highest  importance  to  have,  as  fully  as 
possible,  a  conception  of  the  individual  before  he  became 
afflicted,  so  that  we  may  understand  the  symptoms  which  are 
the  expressions  of  this  reaction. 

The  scheme  of  examination  which  follows  is  directed  pri- 
marily to  elucidating  the  mental  state.  It  is  taken  for  granted 
that  the  student  is  familiar  with  the  various  methods  of  phys- 
ical examination.  The  omission  of  specific  directions  as  to  the 
physical  examination  is  not,  however,  to  be  taken  as  an  indica- 
tion that  it  is  considered  unimportant.  On  the  contrary  a 
physical  examination  in  minute  detail  is  of  the  utmost  impor- 
tance and  unless  it  is  made  the  risk  is  bound  to  be  run  that 
the  key  to  the  whole  situation  will  be  overlooked. 

Mental  disorders  at  best  are  obscure  phenomena  and  no  pains 
should  be  spared  to  illuminate  them  from  every  quarter.  It  is 
not,  of  course,  expected  that  every  possible  physical  test  will  be 
applied  to  each  case.  For  example,  it  would  be  quite  foolish 
to  stain  for  the  malarial  parasite  unless  there  was  some  clinical 
6  65 


66  OUTLINES   OF   PSYCHIATRY. 

evidence  of  malarial  infection.  The  usual  examination  of 
heart,  lungs  and  urine  should,  however,  be  made  in  each  in- 
stance. Similarly  with  the  neurological  examination :  Trous- 
seau's or  Chvostek's  signs  would  hardly  be  thought  of  unless 
tetany  were  suspected,  while  in  every  case  the  reaction  of  the 
pupils  to  light  and  accommodation  and  the  patellar  tendon 
reflex  should  be  recorded  and  in  patients  suspected  of  organic 
brain  disease  or  paresis  the  Babinski  reflex  and  Biernacki's  sign 
would  be  examined  for. 

In  indicating  what  is  important  to  bring  out  in  the  exami- 
nation, the  specific  character  of  the  information  desired  is  set 
forth  for  the  most  part  by  cjuestions,  while  for  more  detailed 
information  special  tests,  which  are  given  in  full,  have  been 
devised. 

The  complete  examination  will  be  considered  under  the  fol- 
lowing five  headings,  the  first  three  of  w^hich  relate  entirely  to 
the  anamnesis  and  the  last  two  to  the  examination  of  the  patient 
himself. 

I.  History  of  the  Family. 
II.  History  of  the  Patient. 

III.  History  of  the  Present  Illness. 

IV.  General  Observation  of  the  Patient. 
V.  Special  Examination  of  the  Patient. 

A.  Physical. 

B.  Neurological. 

^    ,  r  f  General. 

C.  Mental.  <  ^ 

[  Special. 

Special  Tests. 

I.     History  of  Family. 
n  Parents: 

Were  parents  of  patient  related,  or  did  they  dififer  greatly 
in  age? 
'  Mental  Characteristics: of ^aiher  and  Mother: 

What  were  their  mental  characteristics    (i.  e.,  disposition, 
temperament,  etc.)  ? 


EXAMINATION    OF   THE   INSANE.  d^ 

Did  either  have  extraordinary  gifts,  one-sided  talents,  or 
abnormal  traits  ? 
Nervous  and  Mental  Disorders: 

Was  either  nervous  ?     What  were  the  symptoms  ? 

Did  either  have  convulsions? 

Did  either  have  periodical  headaches,  migraine  or  hemicrania  ? 

Was  eitherneurasthenic  ? 

Was  either  ever  insane  ? 

Was  either  at  any  time  a  patient  in  a  hospital  for  nervous 
or  mental  diseases?  Where?  When,  and  how  long  did 
he  or  she  remain?  What  age  at  the  time?  How  long 
after  or  before  the  patient  was  born  ? 

Did  either  have  any  other  disorders  (tics,  etc.)  ? 
Other  Diseases: 

Did  either  have  constitutional  diseases  ?     Syphilis  ?     Tuber- 
culosis?    Diabetes?     Arthritis? 
Alcohol: 

Was  either  addicted  to  the  use  of  alcohol  ?  How  much  did 
they  take  (in  day,  week,  month,  etc.)  ? 

How  long  was  it  taken  (years)  ? 

What  was  the  result?     Did  either  have  delirium  tremens? 
Crime  and  Suicide: 

Was  either  a  criminal?  What  crimes  did  either  commit? 
Was  he  or  she  punished  by  law  ?  What  was  the  punish- 
ment? 

Did  either  commit  or  attempt  suicide?     Under  what  circum- 
stances ? 
Defects  of  Siblings:^ 

Did  the  siblings  of  either  father  or  mother  die  young  ?  What 
were  the  causes  of  death  ? 

Were  the  siblings  of  either  congenitally  deformed?  Were 
any  blind?     Deaf?     Dumb? 

Did  siblings  of  either  have  convulsions  or  other  nen^ous 
disease? 

'  Siblings   is   a   convenient  term  used  to  denote  children  of  the   same 
parent. 


68  OUTLINES    OF    PSYCHIATRY. 

Were  any  insane,  or  patients  in  a  hospital  for  nervous  or 

mental  diseases? 
Grandparents: 

If  there  appears  to  be  a  hereditary  taint,  get  details  as  in  the 

above  questions  for  both  the  maternal  and  the  paternal 

grandparents. 
Siblings  of  Patient: 

Are  or  were  there  siblings  of  patient?    Give  in  order  (noting 

male  and  female),  and  get  age,  if  living,  or  age  at  and 

cause  of  death.     Inquire  regarding  nervous  and  mental 

diseases  as  in  questions  above. 

11.     History  of  Patient. 
Full  Name  and  Age: 

(In  years  and  months.) 
Address: 

What  is  the  address  of  the  patient  ?     How  long  has  he  lived 
there  ? 
Occupation: 

What  is  the  business,  profession  or  occupation  of  the  patient? 

How  long  has  he  been  thus  occupied  ? 
What  previous  occupations  has  he  had  ?     Get  the  details  of 
how  long  he  has  retained  each  position,  how  successful  he 
was  in  each  one,  and  why  he  left  ? 
Birth: 

At  the  time  of  the  birth  of  the  patient  did  the  mother  have 
difficult  labor?     Were  instruments  used?     What  was  the 
cause  of  the  obstetrical  difficulty  ? 
Early  Childhood: 

Had  the  patient  convulsions  in  childhood  ?  How  old  was  he 
or  she  when  these  began?  How  many  years  did  they 
continue?  How  long  was  each  seizure?  Give  details 
regarding  their  character  {e.  g.,  loss  of  consciousness; 
local  or  general ;  how  brought  on ;  etc. ) . 
Had  the  patient  rickets  ? 

What  other  diseases  in  childhood   did   the  patient  have? 
When,  and  with  what  result? 


EXAMINATION    OF   THE  INSANE.  69 

When  did  he  learn  to  walk? 

When  did  he  learn  to  talk? 
School: 

When  did  he  first  attend  school  ?     Where  did  he  go  ?     How 
long  did  he  remain  at  school?     Why  did  he  leave?     In 
school  was  he  bright,  average,  or  stupid  ? 
Injuries  and  Diseases  in  Later  Life: 

Has  the  patient  had  any  head  injuries  or  convulsions  (i.  e., 
beyond  what  was  mentioned  in  answer  to  question  above)  ? 

Has  he  had  gonorrhea? 

Has  he  had  syphilis? 

What  treatment  for  the  latter  did  he  receive,  and  what  were 
the  after  effects  ? 

What  other  diseases  has  patient  had  ?     What  were  the  after 
effects  ? 
Alcohol: 

Has  patient  taken  alcohol  in  any  form  (beer,  wine,  whiskey, 
tonic  medicines,  etc.)  ?  How  much  of  each  has  he  taken, 
by  the  day,  week,  or  month?  How  long  has  he  been 
taking  alcohol?  Has  he  become  drunk?  Has  he  ever 
had  delirium  tremens?  Has  the  alcohol  made  him  pleas- 
ant or  disagreeable? 
Other  Habits: 

Has  the  patient  taken  drugs,  such  as  cocaine,  morphine, 
opium,  or  any  others  for  long  periods  of  time? 

Has  he  used  tobacco  ?     Did  he  smoke,  chew  or  snuff?     How 
much  tobacco  did  he  use  in  a  day ;  in  a  week  ? 
Marriage  and  Children: 

Is  or  has  the  patient  been  married  ?  When  was  he  married  ? 
Is  the  (husband)  wife  still  living?  How  many  times  has 
he  been  married? 

Has  the  married  life  been  happy?     If  not,  why  not? 

Has  the  patient  or  wife  any  gynecological  or  menstrual  diffi- 
culties ?  When  did  catamenia  begin  ?  Has  it  been  regu- 
lar?    When  did  catamenia  end? 

Has  the  patient  or  wife  had  abortions  or  miscarriages? 


JO  OUTLINES    OF    PSYCHIATRY. 

Give  the  details.     (How  often,  when,  and  how  were  they 

brought  about.) 
How  many  children  has  patient  had?     Give  them  in  order, 

noting  sex,  ages,  nervous  and  mental  diseases,  etc. 
Previous  Attacks: 

Has  the  patient  had  similar  attacks  before?     What  were 

the  symptoms?     How  long  did  the  condition  last?     Did 

he  go  to  a  hospital  for  nervous  or  mental  diseases  ? 
If  he  has  not  had  similar  attacks  before,  inquire  if  he  has 

had  periods  of  depression  or  of  exaltation,  how  long  these 

lasted,  what  was  done  during  these  attacks,  etc. 
Get  any  further  details  about  the  disposition  of  the  patient; 

how  he  got  on  with  his  companions,  whether  or  not  he 

was  sociable,  moody,  inclined  to  look  on  the  bright  or  the 

dark  side  of  things,  etc. 

HI.     History  of  the  Present  Illness. 
Cause  and  Onset: 

Did  the  present  illness  come  on  as  the  result  of  an  accident 

or  disease?     Did  the  patient  have  a  physical  or  a  mental 

shock  ?     Has  he  been  under  extraordinary  strain  for  some 

time?     Is  the  present  attack  thought  to  be  due  to  excess 

of  any  sort?     Specify. 
Did  the  attack  come  on  gradually  or  suddenly? 
General  Physical  and  Mental  Changes: 

Has  there  been  a  change  of  character  in  the  patient?     Has 

he  been  agreeable  to  his  wife  (husband)  and  children,  to 

friends  and  neighbors  ? 
Has  he  appeared  to  be  dazed,  or  quiet,  or  restless  ?     Has  he 

been  excited? 
Has  he  been  tidy  in  feeding  and  in  his  other  habits  ? 
Has  he  spoken  much  or  little,  or  has  he  been  dumb? 
Has  he  slept  well?     How  many  hours  has  he  slept  each 

night?     Has  he  slept  regularly? 
Has  he  eaten  well,  or  little?     Has  he  had  a  perverse  or 

abnormal  appetite?     Has  he  taken  his  meals  regularly? 


EXAMINATION    OF   THE   INSANE.  71 

Does  he  give  any  explanation  for  his  poor  appetite  or  his 
refusal  to  eat  food? 

What  was  the  patient's  weight  before  the  illness  began  ? 

What  other  changes  in  the  physical  condition  of  the  patient 
have  been  noted  since  the  beginning  of  the  illness  ?     Has 
he  been  tremulous  in  hands  or  in  speech  ?     Has  he  become 
bald  or  has  the  hair  whitened  ? 
Emotional  Condition: 

Has  the  patient  been  depressed,  or  unduly  joyful,  or  apathetic? 

Has  he  been  passionate,  or  inclined  to  anger,  or  threatening? 
Hallucinations  and  Delusions: 

Has  he  heard  imaginary  voices  ?     What  have  they  said  ? 

Did  he  go  through  the  house  looking  under  the  beds  and  the 
furniture,  and  in  the  cupboards?  Did  he  listen  in  cor- 
ners, or  at  the  walls?  Did  he  look  at  definite  points  for 
some  time? 

Has  he  had  ideas  of  persecution,  or  of  grandeur? 

Do  the  delusions  change? 
Suicide  and  Homicide: 

Has  he  made  attempts  at  suicide;  at  homicide?     What  were 
the  exciting  causes  ? 
Intellectual  and  Memory  Defects: 

Has  he  shown  any  intellectual  defect  ?  Has  he  been  able  to 
carry  on  his  business  in  the  proper  manner?  Has  he 
made  peculiar  or  ill-advised  purchases  ? 

Has  he  shown  any  defect  in  memory  ?  Has  he  remembered 
his  business  engagements?  Does  he  recognize  his  friends 
or  relatives?  Does  he  mistake  persons?  Has  he  kept 
track  of  the  days  of  the  week  and  of  the  month  ?  Has  he 
known  where  he  has  been  ? 
Moral  and  Legal  Laxncss: 

Has  the  patient  offended  against  the  law ;  against  morality  ? 
How  did  he  so  offend  and  with  what  result  ? 
Insight : 

Has  he  understood  that  he  has  been  mentally  different  than 
he  is  normally?  Does  he  appreciate  the  nature  of  his 
disorder? 


72  OUTLINES    OF    PSYCHIATRY. 

Miscellaneous: 

Has  the  patient  any  indications  of  stereotypy,  or  of  cata- 
lepsy, of  apparent  playfulness,  of  impulsive  actions  ? 

Add  any  other  information  that  the  informant  can  give 
regarding  mental  changes  in  the  patient. 

Note  the  name  and  address  of  the  informant,  and  the  rela- 
tion he  bears  to  the  patient. 

IV.     General  Observation  of  the  Patient. 

Is  he  in  bed,  about  the  ward,  on  parole? 
Facial  Expression : 

Does  the  patient  look  sad,  fearful,  gay,  hostile,  suspicious, 
visionary,  expressionless,  intent,  arrogant,  sleepy,  cyanotic, 
demented  ? 
Movetnents-' 

Are  there  movements  of  the  body,  of  the  head,  of  the  face? 
Is  there  Schnauzkrampf  ?  Are  there  rhythmic  quiverings 
of  the  mouth?  Are  there  wrinklings  of  the  forehead? 
Are  there  stereotyped  movements  ? 

Does  the  patient  walk  straight  and  to  some  purpose  ?     Does 
he  walk  irregularly  or  go  from  one  thing  to  another? 
Does  he  go  slowly  or  quickly  ? 
Appearance  and  Demeanor: 

How  does  he  carry  his  hands  ?     Is  his  hair  tidy  or  unkempt  ? 
Is  he  fully  dressed,  half-dressed,  or  naked  ?     Is  his  cloth- 
ing well  kept?     Does  it  show  that  he  has  been  untidy  in 
feeding  and  in  drinking?     Do  the  clothes  fit  the  patient? 
Mental  Observations: 

Did  he  voluntarily  complain  of  ill-being  or  ill-treatment,  or 
speak  of  his  delusions,  or  his  feelings  ? 

Was  he  coherent  ? 

Was  it  difficult  to  keep  him  on  the  line  of  questioning? 

Did  he  cooperate  in  the  mental  and  physical  examinations,  or 
did  he  raise  objections  to  them? 

How  did  he  receive  the  visits  of  the  physicians? 


EXAMINATION    OF   THE   INSANE.  73 

V.     Special  Examinations  of  the  Patient. 

A.  Physical  Examination. 

B.  Neurological  Examination. 

1.  Reflexes: 

a.  Superficial  or  skin  reflexes. 
h.  Deep  or  tendon  reflexes. 

c.  Organic  or  visceral  reflexes. 

d.  Pupillary  reflexes. 

2.  Sensation: 

a.  Vision: 

visual  acuity. 

visual  fields ;  hemianopia,  contractions  ? 

color  vision. 

entoptic  phenomena. 

ophthalmoscopic  examination. 

hallucinations,  character? 
h.  Hearing: 

acute,  sub-acute,  or  deaf? 

test  of  air  and  bone  conduction. 

high  and  low  tones  ? 

subjective  noises,  voices? 

c.  Taste : 

bitter,  sweet,  salt,   sour. 

subjective  tastes,  before  or  after  meals? 

d.  Smell: 

tests  with  solutions. 

subjective  smells,  referred  to  self  or  en- 
vironment ? 

e.  Touch : 

touch  threshold  on  the  head,  neck,  arms, 
hands,  legs,  feet,  abdomen,  chest. 

accuracy  of  localization  on  the  head,  neck, 
arms,  hands,  legs,  feet,  abdomen,  chest. 

double  point  threshold  on  the  head,  neck, 
arms,  hands,  legs,  feet,  abdomen,  chest. 


74  OUTLINES    OF    PSYCHIATRY. 

/.  Pressure: 

discrimination. 
g.  Pain. 

threshold  on  the  head,  neck,  arms,  hands. 
legs,  feet,  abdomen,  chest. 
h.  Temperature : 

perception  of  temperatures. 

perception  of  differences. 
i.  Stereognistic  sense. 
/.  Joint  and  muscle  sense: 

passive  movements. 

active  movements. 
k.  Organic  Sensations : 

hunger. 

thirst. 

fatigue. 

sexual. 

desire  for  urination. 

desire  for  defecation. 
/.  Subjective  organic  sensations. 

formication. 

hyperesthesia. 

hyperalgesia, 

anesthesia. 

analgesia. 

feeling  of  reality. 
3.  Movement: 

a.  Rapidity  of  movement. 

b.  Accuracy  of  movement. 

c.  Force  of  movement. 

d.  Limited  movements. 

e.  Movements  of  special  parts. 
C.  Mental  Examination  of  Patient. 

General  Memory  and  Orientation : 
What  is  your  full  name? 
Where  were  you  born  ?     Where  do  you  live  ? 


EXAMINATION    OF   THE   INSANE.  75 

What  is  your  age  ? 

In  what  year  were  you  born? 

What  year  is  this  ?    What  month  is  this  ?    What 

day  of  the  month?      What  day  of  the  week 

is  it? 
(If  the  answers  to  the  foregoing  questions  are 

not  consistent,  try  to  get  the  patient  to  ex- 
plain the  discrepancy.) 
What  city  is  this  ?     What  place  is  this  ?     How 

far  from  your  home  is  this? 
When  did  you  come  here?    How  long  have  you 

been  here? 
Who  brought  you  here?     How  did  you  come? 
What  did  you  do  when  you  arrived? 
Whom  did  you  see  when  you  arrived?      Did 

you  ever  see  me  before?     What  is  my  name? 

What  is  his   (other  physician's)   name? 
When  did  you  get  up  this  morning?     Did  you 

have  breakfast?     What  did  you  have?     Did 

you  have  dinner?      Did  you  have  supper? 

What  did  you  have  for  those  meals  ? 
Has  any  one  visited  you?      Who  was  it?      Is 

he  a  relative?     When  did  he  come? 
General  Understanding  and  Insight: 

What  kind  of  a  place  is  this?     What  kinds  of 

people  are  here?     Who  are  they  (patients)  ? 
Who  are  they  (nurses  and  attendants)  ?     Who 

am  I,  or  who  are  we  (physicians)  ? 
Why  are  you  here?     Did  you  want  to  come? 
Is  there  anything  wrong  with  you?      Are  you 

sick  ?    Do  you  feel  quite  well  ?    Is  your  mind 

all  right? 
Special  Memory : 

Family:  What  are  the  names  of  your  parents? 

Are    they    living?       Where    do    they    live? 

What  was  the  name  of  your  mother  before 


76  OUTLINES    OF    PSYCHIATRY. 

she  was  married?  How  many  brothers  and 
sisters  did  you  have?  Give  their  names? 
Are  they  all  living?  Which  ones  are  dead? 
Of  what  did  they  die?  How  old  were  they 
at  time  of  death?  Where  do  those  living 
live?      What  do  they  do? 

School:  Where  did  you  first  go  to  school? 
What  age  were  you  at  that  time?  What 
other  schools  did  you  attend?  Give  the 
names  of  some  of  your  teachers? 

Occupations:  What  is  your  occupation?  When 
did  you  first  go  to  work?  What  age  were 
you?  What  year  w^as  that?  What  other 
work  have  you  done?  Give  the  dates  and 
the  time  for  each  position  that  you  have  had, 
and  tell  why  you  left  each  place. 

Marriage  and  Children:  Are  you  married? 
When  were  you  married?  How  long  ago  is 
that?  What  w^as  your  wife's  (or  your) 
maiden  name?  Have  you  children?  When 
were  they  born  ?  How  many  are  now  living  ? 
How  old  are  those  now  living?  What  are 
their  names?  Where  do  they  live?  How 
many  are  dead?  How  old  were  those  that 
died?  Of  what  diseases  did  they  die?  Has 
your  wife  (or  you)  had  miscarriages  or 
abortions  ? 

Diseases:  What  diseases  did  you  have  as  a  child? 
Did  you  ever  have  convulsions?  In  these 
did  you  lose  consciousness?  Did  you  ever 
have  a  blow  on  the  head  or  a  fall?  Have 
you  had  syphilis?  Were  you  treated  for 
this  ?  How  long  ago  did  you  have  it  and  how 
long  did  the  treatment  continue?  Did  your 
hair  fall  out?  Did  you  have  sores  on  your 
penis  (or  vulva)  and  other  parts  of  the  body? 


EXAMINATION    OF   THE   INSANE.  JJ 

Other  details  of  the  effects  of  the  syphilis? 
Alcohol:  Do  you   take  alcohol   in   any   form? 

How  much  do  you  take  (number  of  glasses 

a  day  or  week)  ?    Have  you  ever  been  drunk? 

Have  you  ever  had  delirium  tremens? 
Other  Drugs. — Have  you  ever  taken  cocaine  or 

morphine  ?     How  long  have  you  taken  them  ? 

How  much  have  you  taken  in  a  day? 
Special  Examination  About  the  Present  Condition: 
Special  Insight  Into  the  Condition  : 

Emotional:  Do  you  feel  all  right,  or  depressed, 

or  excited,  or  indifferent?      Are  you  always 

this  way?      If  not,  how  are  you  at  other 

times?      How   were  you   six   months   ago? 

When  did  this   feeling  begin?      What  was 

the  cause  of  it?      Did  it  come  on  suddenly? 

Are  you  sad  or  afraid? 

a.  Have  you  had  any  peculiar  experiences? 

h.  Is  anything  being  done  to  you  or  has  any- 
thing been  done  to  you  to  make  you  sad 
or  afraid? 

c.  If  not,  why  are  you  sad  or  afraid? 

d.  What  do  you  fear? 

e.  Do  you  think  you  are  being  watched,  or 

talked  about? 

/.  Have  people  been  persecuting  you,  or  have 
they  tried  to  poison  you,  or  to  rob  you, 
or  to  influence  your  mind,  or  to  compel 
you  to  do  things  that  you  do  not  wish 
to  do? 

g.  Who  are  trying  to  do  these  things? 

h.  Why  do  they  do  it? 

i.  How  have  your  companions  and  your 
friends  treated  you?  How  has  your 
wife  (or  husband)  treated  you? 

y.  Has  this  been  planned  out? 


78  OUTLINES    OF    PSYCHIATRY. 

k.  What  makes  you  think  so?      (Get  a  full 
account   of   the   systematization   of   the 
delusions  and  note  especially  the  retro- 
spective interpretations  and  the  falsifica- 
tions of  the  same.) 
Bodily:  Is  your  bodily  condition  good?    Do  you 
feel  physically  well?      (Get  a  voluntary  ac- 
count of  any  peculiar  bodily  feeling  of  the 
patient,  and  if  this  is  not  possible  carefully 
question,  using  as  few  leading  questions  as 
possible,  to  bring  out  any  localized  or  general 
feeling  of  bodily  change,  etc.) 
Head:  Does  your  head  feel  all  right?     How  is 
your  mind?       (If  there  is  insight  into  the 
condition,  get  a  full  account  from  the  patient 
of  what  he  thinks  regarding  the  changed  con- 
dition.) 

a.  Do  you  have  peculiar  thoughts? 

b.  Do  thoughts  to  do  or  say  things  spring  up 

in  your  mind? 
Auditory  Hallucinations: 
a.  Do  you  hear  things? 
h.  Are  they  noises? 

c.  When  do  you  usually  hear  them?      Are 

they  heard  oftener  when  you  are  alone, 
or  with  other  people? 

d.  Where  do  they  come  from?      From  the 

people  about  you,  or  from  the  walls  and 
ceilings,  or  from  other  rooms? 

e.  If  voices,  can  you  recognize  them?     Are 

they  plain  ?  Are  they  real  voices  or  only 
thoughts?  Do  you  hold  conversations 
with  them  ?  Do  you  reply  to  their  ques- 
tions or  to  what  they  say?  Do  you  re- 
ply aloud,  or  do  you  only  think  the  reply  ? 
Do   they    say   pleasant   or   disagreeable 


EXAMINATION    OF   THE   INSANE.  79 

things?  Do  the  voices  or  noises  go  on 
continually?  Do  they  stop  when  other 
people  talk  with  you,  or  when  you  talk, 
or  when  you  listen  to  other  things,  for 
example,  music? 
Visual  Hallucinations: 

a.  Do   you   see   things?      Are   they  people, 

or  animals,  or  things? 

b.  When  do  you  usually  see  them,  in  day- 

light, in  the  dark,  when  you  are  in  bed, 
when  your  eyes  are  open  or  shut? 

c.  Do  they  move  or  remain  in  one  place  ?    Do 

they  seem  to  be  in  special  places  on  the 
floor,  in  the  corners  of  the  room  ? 

d.  Do  they  always  seem  to  be  in  front  of 

your  eyes  ?     Can  you  get  rid  of  them  by 
turning  your  head? 

e.  Do    they    seem    natural?       Are   they    the 

colors  you  would  expect  such  things  to 
have?      Are  they  transparent,   so   that 
you  can  look  through  them? 
/.  Can  you  get  them  to  disappear.      How  do 
you  do  this? 
Memory:  Is  your  memory  good?      Has  it  al- 
ways been   good    (or  poor)    as   it  is   now? 
Have    you    difficulty    in    remembering    any 
special  things? 
Attention:  Can  you  attend  to  things  as  well  now 

as  you  could? 
Thinking:  Can  you  think  well?  Do  you  under- 
stand readily  what  is  said  to  you?  Does  it 
take  you  some  time  to  think  out  the  answer 
to  questions?  Do  you  understand  what  you 
read? 
Capability:  Can  you  do  things  as  well  now  as 
you  could?      Do  you  have  any  difficulty  in 


80  OUTLINES    OF    PSYCHIATRY. 

fixing  your  mind  on  a  thing  ?  Have  you  any 
difficulty  in  starting  to  do  things?  Do  you 
feel  more  disinclined  to  get  up  in  the  morning 
than  you  used  to  do?  Have  you  any  diffi- 
culty in  dressing,  in  eating,  in  speaking,  in 
walking?  Do  you  feel  able  to  go  to  work? 
Sleep:  Do  you  sleep  well?  How  many  hours 
at  night  ?  Do  you  ever  sleep  in  the  day  time  ? 
Do  you  feel  rested  after  your  sleep? 
Dreams:  Do  you  dream?  How  often  do  you 
dream  ? 

a.  Do  you  dream  of  things  that  have  hap- 
pened to  you  recently,  or  some  time  ago. 
h.  Do  you  dream  of  seeing  things,  or  of  hear- 
ing things,  or  of  things  tasted,  smelled, 
touched,  etc.  ? 

c.  Do  you  dream  of  imaginary  and  of  im- 

possible things? 

d.  Does  the  same  dream  come  twice  or  more? 

Do  they  change  every  time? 

e.  Are  the  dreams  pleasant  or  disagreeable? 
Get  the  patient  to  describe  as  accurately 

as  he  can  one  or  more  of  his  dreams,  and 
if  he  cannot  at  the  time  remember  them, 
tell   him   that  you   will   ask   him   again 
about  them  and  to  try  to  remember  any 
that  occur  until  you  ask  him  again. 
Explanation:  Bring  up  before  the  patient  some 
of  the  things  mentioned  in  the  history  of  his 
case  as  obtained  from  his  relatives  or  physi- 
cian, and  get  him  to  explain  the  events. 
a.  Impulsive  or  peculiar  actions. 
h.  Suicidal  or  homicidal  attempts. 

c.  Hallucinations  and  delusions. 

d.  Moral  laxness. 

e.  Lack  of  judgment. 


examination  of  the  insane.  8 1 

Special  Tests: 
Speech: 

Motor- Vocal : 

Does  the  patient  answer  quickly  or  slowly? 
Does  he  stammer,  or  stutter,  or  slur  or 
jumble  his  words?     Is  there  "jargon" 
speech  ? 
Have  him  repeat  some  of  the   following 
words    and    phrases,    and    describe    the 
character  of  the  repetition,  whether  nor- 
mal, slurring,  etc. 
Third  riding  artillery  brigade. 
Peter  Piper  picked  a  peck  of  pickled  pep- 
pers. 

Conservative.  Perturbation. 

Statistical.  Fastidiousness. 

Irretrievable.  Autobiography. 

Are  there  twitchings  of  the  facial  muscles, 
of  the  lips,  etc.,  while  the  patient  is  speak- 
ing?    Are  there  tremors? 
Motor-Written : 

Have  the  patient  write  his  name,  the  date 
of  his  birth,  the  city  in  which  he  lives, 
the  name  of  the  present  place,  and  the 
date. 
Have  him   write   from   dictation   a   short 
sentence  or  phrase.     E.  g., 
The  United  States  of  America. 
The  evening  has  come. 
Contentment  is  a  pearl  of  great  price. 
Where  shall  I  find  hope? 
Have  him  copy  one  or  more  typewritten 
phrases  or  words. 
Sensory-Hearing : 

Does  the  patient  understand  what  is  said 
to  him  readily? 


82  OUTLINES    OF    PSYCHIATRY. 

Does  he  obey  simple  commands,  e.  g.,  stand 
up,  show  your  tongue,  cross  your  legs, 
squeeze  my  hand?  If  not,  is  it  because 
he  does  not  understand  you  or  is  it  be- 
cause he  will  not? 
If  he  obeys  the  simple  commands,  does  he 
do  so  as  readily  the  more  complicated 
ones?  E.  g.,  Walk  to  the  other  end  of 
the  room,  turn  about  quickly,  walk  back, 
turn  your  chair  around,  sit  down  and 
cross  your  legs. 
Sensory-Visual : 

Does  he  read  words  aloud  correctly  ?    Does 
he   read   numbers,   sentences,   etc.,   cor- 
rectly ? 
Does  he  name  colors  (differentiate  between 
color  blindness  and  inability  to  find  the 
name  for  a  common  color,  e.  g.,  black, 
red,   white),   objects,  and  pictures  cor- 
rectly ? 
Does  the  patient  use  wrong  words  (para- 
phasia) ?     Does  he  have  difificulty  in  get- 
ting the  name  or  the  word  for  a  thing? 
Does   he  have  a  tendency  to   repeat  cer- 
tain words,  and  do  certain  words  recur 
throughout  the  examination  ? 
Apprehension  and  Apperception: 

Summarize  the  results  of  the  examination  of  the 
patient  up  to  this  point  in  respect  to  his  ability  to 
apprehend  and  to  comprehend  the  situation;  how 
much  insight  into  his  condition  he  has,  whether 
he  has  been  quick  or  slow  to  grasp  the  meaning  of 
questions,  whether  or  not  he  seems  able  to  take  in 
more  than  one  thing  at  a  time. 
Have  the  patient  read  aloud  one  of  the  following 
stories,  ask  him  to  give  the  point  of  it  in  his  own 


EXAMINATION    OF   THE    INSANE.  83 

words.  Note  how  well  he  does  the  original  read- 
ing, and  record  accurately  what  he  says  in  giving 
the  content  of  the  story. 

1.  It  is  related  that  at  the  coronation  of  one  of 

the  popes  about  three  hundred  years  ago  a 
little  boy  was  chosen  to  act  the  part  of  an 
angel ;  and  in  order  that  his  appearance  might 
be  as  gorgeous  as  possible  he  was  covered 
from  head  to  foot  with  a  coating  of  gold  foil. 
He  was  soon  taken  sick  and  although  every 
known  means  were  employed  for  his  recov- 
ery, except  the  removal  of  his  fatal  golden 
covering,  he  died  in  a  few  hours. 

2.  A  female  polar  bear  with  two  cubs  was  pur- 

sued by  sailors  over  an  ice  field.  She  urged 
her  cubs  forward  by  running  before  them, 
and  as  it  were,  begging  them  to  come  on.  At 
last  in  dread  of  their  capture  she  pushed,  then 
carried  and  pitched  each  before  her,  until  they 
actually  escaped.  The  polar  bear  is  a  won- 
derful swimmer  and  diver.  In  the  capture 
of  seals  lying  on  the  ice,  it  dives  some  dis- 
tance off  and,  swimrning  underneath  the 
water,  suddenly  comet*  up  close  to  the  seals, 
cutting  off  their  retreat  to  the  sea. 

3.  A  cow-boy  from  Arizona  went  to  San  Fran- 

cisco with  his  dog  which  he  left  at  a  dealer's 
while  he  purchased  a  new  suit  of  clothes. 
Dressed  finely,  he  went  to  the  dog,  whistled 
to  him,  called  him  by  name  and  patted  him. 
But  the  dog  would  have  nothing  to  do  with 
him  in  his  new  hat  and  coat  but  gave  a 
mournful  howl.  Coaxing  was  of  no  effect, 
so  the  cow-boy  went  away  and  donned  his 
old  garments,  whereupon  the  dog  immediately 
showed  his  wild  joy  on  seeing  his  master  as 
he  thought  he  ought  to  be. 


84  OUTLINES    OF    PSYCHIATRY. 

Show  the  patient  for  an  instant  one  of  the  cards  with 
collections  of  figures,  letters,  pictures,  etc.,  such 
as  are  illustrated  below,  and  have  him  tell  you 
what  is  on  the  card,  giving  the  content  in  full  and 
the  relative  positions  of  the  different  elements. 
The  following  apperception  test  may  be  used  if  it 
seems  desirable.  In  this  test  the  patient  is  given 
a  sheet  on  which  is  printed  an  anecdote,  story  or 
description,  but  in  which  certain  words  are  left 
blank.  The  patient  is  to  be  instructed  to  go 
over  the  paper  carefully  and  after  having  once 
gone  over  it  to  fill  in  the  spaces  with  words  that 
will  appropriately  give  the  meaning  to  the  story. 
I.  Once  upon  a  time heard  a chirrup- 
ping  in  the  .      Ah,  he  said  to  himself, 

if  I  could like  that,  how  I  should 

be.      So  be  bowed  low  to  the ,  and  said, 

kind  friend,  what  do  you  eat  to  make 

your  so  sweet?      I  drink  the  evening 

dew,   replied  the  .      The   foolish  

tried  to  live  on  the  same  ,  and  died  of 


2.  Monkeys  are  and  creatures  when 

,   but  become  and  as   they 

grow    ,    especially    the    males.       They 

pass  most  of   their  time   in  alternate  

and  ;  after  a  violent  they  change 

to  the  other  extreme,  and  behave  as  if  they 

were  the  most  of  creatures.      Animals 

at  one  moment  living  in  perfect  and 

become    in    an    instant    deadly  , 

ready  to each  other  to . 

3.  During  the  early  centuries  of  Christian  Spain 

the  conditions  of  the  were  such  that 

every  was  obliged  to  defend  his  

to  the  throne  against  the of  his  family, 


EXAMINATION    OF   THE   INSANE. 


85 


1  4  9 


3  7  4 

9  1  5 


O  T 
R  C 


GREEN  TREE 


3  6 
1  4 


B  N  V 


HOUSE 


DOG 

MOUSE 

CAT 


86  OUTLINES    OF    PSYCHIATRY. 

SO    that   almost   constant   were   being- 
waged   among  the   nearest  kin   and    it   was 

practically   impossible   that   several   of 

weak  and  incompetent should  not  have 

been  wrested  from  the  throne. 
Attention: 

Summarize   the   results   of   the   observations   made 
during  the  examination  of  the  patient.      Describe 
the  character  of  any  apparent  attention  disorder, 
and  if  possible  give  examples  to  show  the  char- 
acter.     In  the  summary  try  to  differentiate  be- 
tween what  is  known  as  "  distractibility,"  wander- 
ing attention,  or  the  shifting  of  the  attention  to 
successive  new  impressions,  and  the  lack  of,  or 
the  fluctuations  of  the  attention  such  as  is  found 
in  senile  and  alcoholic    (Korsakow's   syndrome) 
conditions. 
Should  there  be  an  apparent  fluctuation  of  the  at- 
tention try  one  of  the  following  tests,  to  bring 
out  the  condition  in  a  more  graphic  manner. 
I.  Read   to   the   patient  the    following   series   of 
numbers  at  the  rate  of  one  each  half  second, 
or  the  series  of  letters  in  the  same  way  and 
have  him  tap  with  a  pencil   each   time  the 
number  6  or  the  letter  C  is  read  as  the  case 
may  be. 


4  3 

6  8 

5 

9 

634 

6  5 

247 

6  5 

8 

6 

7 

2 

3663 

7 

6 

3  9  3 

8  6 

7  3^ 

9  3 

5 

6 

4 

8 

8  6 

9  4 

6  8 

946 

7  9 

784 

6  8 

5 

9 

8 

6 

5  3 

286 

9 

8  3  6 

9  7 

286 

76 

4 

3 

8 

5 

7  9 

2  6 

5 

7 

286 

2  8 

769 

64 

3 

7 

2 

8 

TCQNDCBKCJCHAFLCOSMB 
CRFKCLHDACJQSMTCCNFO 
BJCMKRCTAHCDLQCRNCOJ 
CACFKOQHCMLFDCSRCNTB 
SFCTJLCHNAQCRTCKCDBS 


EXAMINATION   OF  THE   INSANE.  8/ 

Note  each  time  a  letter  or  a  number  is  not 
properly  responded  to,  and  see  if  there  is  a 
rhythm  in  the  failure  to  make  the  response. 
2.  Have  the  patient  tap  on  the  tapping  apparatus, 
which  is  a  mechanical  counter,  for  thirty  sec- 
onds and  record  the  number  of  taps  that  he 
makes  in  the  different  periods  of  five  seconds. 
Or,  have  him  make  taps  on  a  sheet  of  paper  to 
and  fro  for  thirty  seconds,  and  note  how  long 
it  takes  him  to  tap  along  one  line. 
Or,  have  him  make  the  taps  in  the  squares  of 
a  sheet  of  cross  section  paper  (having  each 
square  about  half  an  inch  wide),  noting  how 
long  it  takes  him  to  make  the  successive  ten 
taps,  in  the  total  series  of  lOO  taps. 
Memory: 

Summarize  the  results  of  the  questions  which  indi- 
cate the  memory  grasp  of  the  patient.  Include 
under  separate  headings  accounts  of  the  following: 

1.  Recent  and  remote  events. 

2.  Names  of  persons,  including  members  of  his 

family,  the  physicians,  nurses  and  attendants, 
and  other  parties.. 

3.  Date  and  time. 

4.  Places. 

Should  there  appear  to  be  any  memory  defect  try 

the  following  tests. 

I.  Have  the  patient  read  aloud  a  number  of  four 
digits,  or  read  the  number  to  him,  speaking 
each  digit  separately.  This  will  give  respec- 
tively the  visual  and  the  auditory  memories. 

5632  9764  3521 

8629  5941  7368 

6214  9826  5327 


88  OUTLINES    OF    PSYCHIATRY, 

2.  If  the  patient  can  retain  all  of  the  four  digits 

try  him  with  the  six  or  eight  digit  combina- 
tions. 

487631  736491  751924 
955217  972864  249837 
276384     845193     516724 

45319628  19362874  29317586 
35984271  92576438  83264519 
97125684     63258914     87635219 

3.  Give  combinations  of  three  associated  words 

and  have  the  patient  repeat  them  after  you  as 
well  as  he  can. 

Cloak,  hat,  and  gloves. 

Enemy,  battle,  and  peace. 

Station,  train  and  conductor. 

Deer,  horn,  and  hoof. 

Wall,  brick,  and  ivy. 

4.  Another  test  that  may  be  tried  is  the  use  of 

two  or  more  pairs  of  associated  words  of 
which  the  patient  is  to  remember  the  second 
one  of  the  pair.  The  pairs  are  read  to  the 
patient,  he  is  required  to  repeat  them,  and 
after  the  series  (which  may  be  made  up  of 
two,  three,  four  or  more  pairs)  has  been  gone 
over  he  is  given  the  first  word  of  a  pair  and 
asked  what  word  goes  with  it.  The  follow- 
ing pairs  of  words  may  be  used  in  any  com- 
bination of  two,  three,  four,  etc. 

Well — pump.  Game — sport. 

Cent — dime.  Bridge — river. 

Roast — stew.  Dust — sand. 

Oak — pine.  Thumb — toe. 

Drug — medicine.  Cow — horse. 

Water — ice.  Red — brown. 


EXAMINATION    OF   THE   INSANE.  89 

Barrel — bottle.  Law — judge. 

Porch — chair.  Duck — water. 

Glue — wood.  Square — round. 

Street — house.  Face — beard. 

Soap — towel.  Actor — theater. 

Book — paper.  Glove — hand. 

Child — doll.  Potatoes — fish. 
Friend — companion.       Stone — earth. 

Bees — ants.  Tea — sugar. 

Have   the  subject  repeat   the   following,   and 
record  exactly  what  he  says : 
The  alphabet. 
The  names  of  the  months. 
The  days  of  the  weeks. 
The  names  of  the  seasons. 
The  Lord's  prayer. 
Examine  the  patient  in  regard  to  his  memory 
of  school  subjects,  especially  geography  and 
history. 

Which  is  the  longest  river  in  the  U.  S.  ? 

What  is  the  capitol  of  the  U.  S.  ? 

Name  some  of  the  most  important  countries 

in  Europe. 
Name  the  largest  cities  in  the  U.  S.  and  in 

the  different  countries  of  Europe. 
Give  the  dates  of  the  most  important  wars 
of  the  United  States,  and  with  what  coun- 
tries were  they  fought. 
Name  some  of  the  most  noted  presidents, 
etc.,  etc. 
In  addition  to  the  anecdotes  that  were  used  in 
the  apperception  and  apprehension  tests,  which 
give  a  good  idea  of  the  memory  grasp,  have 
the  subject  give  the  substance  of  one  or  more 
of  the  following  sentences  or  anecdotes : 


90  OUTLINES    OF    PSYCHIATRY. 

The  game  of  base-ball  is  fast  taking  hold 
of  the  people  of  Canada,  who  hitherto 
have    been    satisfied    with    the    English 
games  of  cricket  and  foot-ball. 
The  Hindoos  believe  that  the  gradual  dark- 
ening of  the  sun  during  an  eclipse  means 
that  the  jaws  of  a  dragon  are  gradually 
eating  it  up. 
Without  map  or  compass  the  swallows  come 
back  each  year  to  the  places  that  have 
previously  sheltered  them. 
The  advocates  of  universal  peace  will  go  to 
all  sorts  of  extremes  to  get  their  views 
accepted,  for  they  will  fight  those  who 
dare  to  disagree  with  them. 
Pen,  ink,  pencil  and  paper  have  been  the 
most  potent  factors  in  the  advancement 
of  the  world  in  every  way. 
Association: 

The  associations  of  the  patient  may  be  determined 
from  the  general  examination,  from  the  accounts 
of  the  stories  used  in  the  tests  of  apperception  and 
apprehension,  especially  the  test  of  filling  in  the 
fftj.  blank  spaces  on  page  1-9,  from  the  mistakes  made 

in  answer  to  the  memory  tests  4  and  7.  For  more 
extensive  tests  the  follow^ing  series  of  words  may 
be  used.  The  patient  should  be  instructed  to  say 
the  first  word  or  idea  that  comes  into  his  mind 
when  he  hears  a  test  word  that  is  given  him. 
It  is  advisable  often  to  make  note  of  the  time 
between  the  giving  of  the  test  word  and  the  re- 
sponse of  the  patient.  This  can  be  obtained  suffi- 
ciently accurately  by  observing  the  second  hand  of 
a  watch  at  the  time  of  the  experiment.  In  this 
work  it  is  very  important  that  the  replies  of  the 
patient  be  recorded  exactly  as  they  are  given.     If 


EXAMINATION    OF   THE   INSANE.  9I 

there  seems  to  be  no  apparent  connection  between 
the  association  of  the  patient  and  the  test  word 
that  has  been  given  to  him,  try  to  get  him  to  trace 
for  you  the  connection  that  has  gone  on  in  his 
mind ;  for  example,  should  you  give  him  the  word 
*  apple  "  and  he  replied  "  foot,"  the  connection  is 
not  one  that  can  readily  be  recognized,  but  if  on 
questioning  you  find  that  the  word  "  apple  "  sug- 
gested to  him  a  time  when  he  was  under  an  apple 
tree  and  he  walked  on  a  number  of  rotting  apples 
with  his  bare  feet,  the  association  is  more  easily 
understood. 

1.  White.     Red.     Gray.     Dark.     Light. 

2.  Pain.     Rest.     Cold.     Sweet.     Beautiful. 

3.  Head.     Poor.     Man.     King.     Hair. 

4.  Chair.     Bed.     House.     Lamp.     Stairs. 

5.  Mountain.     River.     Sea.     Sun.     Star. 

6.  Tree.     Leaf.     Grass.     Bush.     Flower. 

7.  Luck.     Sick.     Hate.     Fear.     Right. 

TJiinking: 

In  a  previous  section  the  patient  has  described  his 
feeling  regarding  his  ability  to  think  properly  and 
easily.  These  feelings  may  or  may  not  corre- 
spond to  the  actual  state  of  affairs.  There  may  be 
a  feeling  of  ability  without  the  ability  of  perform- 
ance, and  there  may  be  the  feeling  of  inability 
without  any  actual  change  in  the  real  ability.  The 
calculation  tests  of  age,  date  of  birth,  etc.,  may  be 
used  to  get  some  idea  of  the  ability  of  the  patient 
to  think  well,  but  these  figures  are  so  often  used 
that  it  is  not  necessarily  true  that  if  he  gives  them 
correctly  he  retains  his  normal  thinking  ability. 
For  further  testing  the  following  calculations  are 
easy  tests  to  apply. 


92  OUTLINES   OF   PSYCHIATRY. 


Addition. 

Add     73  and  22 

Add     90  and   18 

Add     84  and  25 

Add  106  and  17 

Add  137  and  64 

Subtraction. 

Subtract     7  from 

63 

Subtract  16  from 

192 

Subtract  24  from 

87 

Subtract  35  from  257 
Subtract  19  from     96 

Division. 

Divide  63  by  7 

Divide  45  by  5 

Divide  132  by  11 

Divide  192  by  16 

Divide  15  by  3 

Multiplication. 

Multiply     7  by  9 

Multiply     9  by  13 

Multiply  12  by  15 

Multiply   14  by  11 

Multiply     8  by  13 

In  cases  in  which  it  is  possible  to  give  the  following 
logical  tests,  these  may  very  well  be  used  to  deter- 
mine any  defect  in  thinking.  The  patient  is  to  be 
instructed  to  read  carefully  the  passages  which  are 
given  on  the  sheet,  and  to  say  whether  or  not  the 
conclusion  of  each  of  them  is  correct.  No  attempt 
need  be  made  to  get  him  to  name  or  to  correct  the 
logical  errors,  but  if  the  corrections  are  volunteered 
they  should  be  noted. 

I.  All   roses  are  beautiful;   lilies  are  not   roses; 
therefore  lilies  are  not  beautiful. 


EXAMINATION    OF   THE   INSANE.  93 

2.  Nothing  is  better  than  wisdom;  dry  bread  is 

better  than  nothing;  therefore  dry  bread  is 
better  than  wisdom. 

3.  None  but  savages  were  in  America  when  it  was 

discovered ;  Hottentots  are  savages,  and  must, 
therefore,  have  been  in  America  when  it  was 
discovered. 

4.  Repentance    is   a   good    quahty;    wicked    men 

abound  in  repentance,  and,  therefore,  abound 
in  what  is  good. 

5.  The  object  of  war  is  durable  peace;  therefore 

soldiers  are  the  best  peacemakers. 

6.  No  soldiers  should  be  brought  into  the  field  who 

are  not  well  qualified  to  perform  their  duty; 
none  biit  veterans  are  well  qualified  to  per- 
form their  part,  and,  therefore,  none  but  vet- 
erans should  be  brought  into  the  field. 


CHAPTER  VIII. 
PARANOIA   AND   PARANOID    STATES. 

Paranoia. 

General  Characteristics. — Paranoia  is  a  chronic,  progressive 
psychosis  characterized  by  systematized  delusions  of  persecu- 
tion, and  usually  hallucinations  of  hearing,  and  showing  little 
tendency  to  intellectual  impairment. 

^Etiology. — This  disease  occurs,  probably  exclusively,  in  per- 
/sons  predisposed  by  some  form  of  hereditary  taint.  The 
hereditary  taint  may  be  due  to  various  conditions  in  the  as- 
cendents, viz.,  psychoses,  the  major  neuroses,  pathological  char- 
acter, alcoholism.  Sometimes  an  acute  illness,  worry  or  other 
condition  of  physical  or  mental  stress  may  act  as  exciting  cause, 
s^hile  onanism,  is  said  in  some  instances  to  play  a  part. 

"General  Symptomatology. — When  the  term  "paranoia" 
first  came  into  use  the  number  of  cases  included  under  it  by 
some  alienists  was  tremendous.  It  seemed  as  if  the  descrip- 
tion of  this  new  disease  had  solved  all  the  difficulties  of  psy- 
chiatry, and  large  numbers  of  obscure  and  previously  unsatis- 
factorily classified  cases  were  included  within  its  domain. 
Now,  after  years  of  experience  with  this  disease  type,  the 
pendulum  seems  to  have  swung  to  the  other  extreme  and  we 
are  beginning  to  realize  that  paranoia,  strictly  speaking,  is  a 
rare  disease,  but  that  there  are  many  combinations  which  are 
known  as  paranoid  or  paranoiac  states,  and  that  these  states 
arise  in  the  course  of  other  mental  diseases. 
^  The  basis  upon  which  true  paranoia  has  been  differentiated 
ifrom  other  conditions  has  often  been  on  the  absence  of  intel- 
lectual impairment.  When  a  paranoid  condition  was  asso- 
ciated with  marked  intellectual  impairment  the  diagnosis  has 
been   dementia  precox.      It   seems  to  me  very  questionable 

94 


PARANOIA    AND    PARANOID    STATES.  95 

whether  we  are  not  really  dealing  with  two  extremes  between 
which  every  possible  transitional  form  may  be  found.  It  de- 
pends to  some  extent  to  my  mind  upon  what  we  mean  by 
dementia.  The  woman  whose  case  I  have  quoted  elsewhere, 
who  expressed  the  idea  that  her  husband  was  untrue  to  her, 
did  not  thereby  show  any  signs  of  intellectual  impairment  or 
express  an  idea  which  inherently  showed  any  evidences  of  intel- 
lectual impairment.  When,  however,  she  adduced  as  proof  of 
this  statement  the  fact  that  when  she  looked  out  upon  the  street 
in  the  morning  following  a  snow  storm  of  the  night  before  she 
saw  numerous  foot-prints  of  a  woman  who  had  been  to  the 
house  during  the  night  to  meet  her  husband,  and  without  any 
additional  facts  presents  this  argument  in  support  of  her  pre- 
vious statement,  it  would  seem  that  we  are  justified  in  saying 
that  her  judgment  in  this  specific  instance  is  poor,  and  when 
we  find  that  all  of  her  arguments  in  support  of  her  idea  are  of 
a  similarly  flimsy  and  unwarranted  character,  we  are  warranted 
in  saying  that  her  judgment  is  impaired,  and  to  my  mind  im- 
pairment of  judgment,  when  permanent,  is  properly  a  symptom 
of  dementia,  and  although  this  patient  talks  reasonably  about 
most  things,  is  acute  to  perceive,  and  under  ordinary  circum- 
stances shows  no  outward  signs  of  mental  disturbance  or  im- 
pairment, yet  I  cannot  see  how  we  are  to  escape  the  conclusion 
that  impairment  actually  exists.  If  this  condition  can  be  called 
dementia  in  its  earliest  manifestations,  then  its  separation  from 
the  more  marked  conditions  to  which  the  term  "  dementia " 
is  usually  applied  is  a  separation  only  in  degree, 
/'^he  weakness  of  judgment  that  the  paranoiac  shows,  how- 
ever, is  not  a  weakness  that  appears  to  be  equally  diffused  over 
the  entire  field  of  the  mental  operations.  It  would  appear  to 
be  more  or  less  closely  associated  with  the  delusional  system. 
We  must  not  on  that  account  come  too  speedily  to  the  old 
conclusion  that  a  person  may  be  insane  on  one  subject  and 
sane  on  all  others.  It  is  true  the  reasoning  of  the  paranoiac 
often  seems  clear  on  subjects  not  connected  with  his  delusions, 
but  we  must  not  lose  sight  of  the  fact  that  the  delusion  itself 


g6  OUTLINES    OF    PSYCHIATRY, 

does  not  constitute  insanity — it  is  only  its  outward  and  mani- 
fest expression.  In  this  respect  Mercier  very  aptly  compares 
the  delusion  to  an  island  in  the  ocean.  The  island  seems  to 
occupy  a  position  completely  isolated,  surrounded  on  all  sides 
by  water,  but  if  the  depths  of  the  ocean  be  sounded  it  will  be 
found  that  it  is  in  reality  but  the  summit  of  a  mountain  which 
reaches  down  into  the  depths  of  the  sea  to  its  very  bottom  and 
so  establishes  a  connection  by  direct  continuity  with  the  main- 
land. So  with  the  delusion,  its  isolation  is  only  apparent,  in 
reality  it  springs  from  the  very  foundations  of  the  mental  life. 

Besides  the  characteristic  attributed  to  paranoia,  of  not 
dementing,  which  has  been  discussed  above,  it  has  been  claimed 
that  the  disease  ran  its  course  without  emotional  disturbances 
other  than  could  be  directly  attributed  to  the  delusions  present. 
Wernicke  maintains  this  general  position  by  setting  forth  that 
while  the  content  of  thought  is  disordered,  the  form  of  thought 
or  the  process  of  thinking  is  preserved. 

This  theory  of  the  disease  harks  back  to  the  "  faculty  con- 
cepts "  of  the  old  psycholog}'.  If  the  thesis  of  the  continuity 
of  mental  processes  that  I  have  maintained  in  the  early  part  of 
this  work  is  true,  then  such  a  state  of  affairs  could  hardly  be 
conceived  of  as  possible.  As  a  matter  of  fact,  I  believe  that 
a  careful  study  of  cases  will  show  primary  states  of  depression 
in  the  early  stages  and  the  symptoms  of  the  early  stages  espe- 
cially, to  my  mind,  are  more  satisfactorily  explained  on  this 
basis. 

The  symptoms  of  the  early  stages  culminating  in  the  sys- 
tematized delusion  of  persecution  are  symptoms  which  lead  up 
to  and  develop  the  paranoiac  cJiaractcr.  This  paranoiac  char- 
acter is  a  character  the  essential  trait  of  which  is  a  general 
feeling,  mood,  or  as  it  is  sometimes  called  affect-tone  of  sus- 
picion. If  we  conceive  of  the  wave  of  consciousness  as  occur- 
ring in  a  sea  of  feeling,  of  affects,  then  we  can  understand  how 
all  of  the  perceptions  of  the  outer  world,  received  and  bathed 
in  this  sea,  must  be  affected  by  its  nature.  If  the  mood  is  one 
of  suspicion,  then  all  the  experiences  of  life  are  contaminated, 


PARANOIA    AND    PARANOID   STATES.  97 

and  the  world  at  large  is  only  interpreted  as  the  perceptions  of 
that  world  are  tinctured  by  the  predominant  mood. 

After  all,  it  is  the  "  feeling-mass  "  more  than  the  intellectual 
processes  that  go  to  make  up  character,  and  the  paranoiac 
character  is  what  it  is  because  this  feeling-mass  has  become  per- 
verted. J.  B.  Pratt  has  well  said  :  "  For  it  is  feeling  alone  that 
gives  value  to  life.  Sensation  and  ideation  merely  report  on 
the  facts.  If  man  were  only  a  cold  intellect  who  saw  and 
judged,  one  thing  would  be  to  him  as  valuable  as  another — in 
fact  for  him  there  would  be  no  values  in  the  universe  but  only 
truths.  It  is  only  because  man  has  feelings,  emotions,  im- 
pulses, that  anything  in  heaven  or  earth  has  value.  Moreover, 
not  only  does  the  feeling  back-ground  create  values ;  it  also  is 
often  that  part  of  a  man's  mental  make-up  which  for  others 
has  value.  What  we  love  in  our  friend  is  not  his  sensations, 
nor  chiefly  his  ideas  and  his  reasoning  power;  it  is  principally 
that  combination  of  indefinable  psychic  qualities — impulses,  de- 
sires, likes  and  dislikes — which  we  call  his  disposition.  So  far, 
then,  is  the  feeling-mass  from  being  something  which  a  man 
should  hope  in  the  course  of  evolution  to  get  rid  of,  that  as  a 
fact,  if  he  should  get  rid  of  it,  no  one  would  be  able  to  find 
anything  lovable  in  him,  and  he  himself  would  be  utterly  unable 
either  to  love  or  even  to  value  anything. 

"  In  short,  the  feeling-mass  is  wider  than  the  other  depart- 
ments of  psychic  life,  and  more  closely  identified  with  the  self. 
A  change  in  it  means  a  change  in  personality.  Sensations  and 
ideas  have  a  communicable  and  universal  nature ;  this  irrational 
residuum  is  peculiarly  private  and  individual.  It  is  the  deter- 
minant of  character — in  one  sense  it  is  the  character  and  the 
personality.  From  it  the  practical  activity  gets  most  of  its 
energy'  and  most  of  its  guidance." 

Special  Symptomatology. — This  disease  usually  occurs  in 
young  adults  who  quite  often,  itthetr  history  Ts  carefully  taken, 
have  shown  peculiarities  during  their  childhood,  manifesting 
themselves  in  a  certain  taciturnity,  moroseness,  or  disinclina- 
tion to  associate  with  other  children  as  freely  as  is  usual.    The 


98  OUTLINES   OF    PSYCHIATRY. 

child  may  also  have  shown  a  tendency  to  make  friends  with 
older  persons,  stay  at  home  and  read  and  sew  instead  of  play, 
and  may  have  had  a  tendency  to  day-dreams  and  the  building 
of  air-castles.  Very  often,  however,  the  history  obtained  will 
show  none  of  these  peculiarities. 

For  the  purpose  of  description  the  disease  may  be  divided 
into  three  stages,  named  in  accordance  with  their  most  char- 
acteristic symptoms.  First,  the  hypochondriacal  stage  or  stage 
of  subjective  analysis.  Second,  the  stage  of  persecution.  Third, 
the  stage  of  transformation  of  the  personality. 

In  the  first  stage  the  symptoms  already  described,  if  present, 
become  more  marked,  the  patient  becomes  wrapped  up  in  his 
own  thoughts  and  uncommunicative,  unusual  feelings  occur, 
headaches,  dizziness,  weakness,  perhaps  insomnia,  with  ner- 
vousness and  restlessness,  which  he  fails  to  understand,  but 
constantly  worries  about — hypochondriacal  ideas.  This  con- 
dition is  associated  with  marked  emofional  depression,  which  in 
some  degree  is  probably  always  incident  to  beginning  paranoia. 
He  soon  begins  to  notice  that  people  act  differently  towards 
him,  when  he  goes  in  a  room  someone  gets  up  and  goes  out, 
people  on  the  street  spit  when  they  pass  him,  his  employer  has 
failed  to  say  "  good-morning  "  to  him  lately,  people  who  are 
standing  about  here  and  there  are  talking  about  him  and  speak- 
ing of  his  condition  and  making  disparaging  remarks.  Every- 
thing that  occurs  about  him  is  interpreted  as  having  some  rela- 
tion to  himself — delusion  of  relativity.  This  condition  con- 
tinues, becomes  more  aggravated,  the  ideas  are  not  corrected 
and  the  patient,  by  keeping  by  himself,  fails  to  come  into  that 
normal  touch  with  the  environment  which  gives  to  acts  and  cir- 
cumstances their  proper  perspective. 

The  hypochondriacal  ideas  and  delusions  of  relativity  become 
more  constant  and  pronounced,  the  patient  fears  he  is  losing 
his  reason,  his  health  is  being  destroyed,  and  all  for  what  pur- 
pose? what  is  the  explanation  of  these  conditions?  why  do 
people  act  towards  him  as  they  do? 

The  second  stage  of  the  disease  is  ushered  in  by  the  delusion 


PARANOIA    AND    PARANOID    STATES.  99 

of  persecution,  which  is  the  patient's  answer  to  all  these  queries 
by  finding,  as  he  believes,  that  their  explanation  lies  in  the 
operation  of  some  malign  influence  against  him.  About  this 
time  also  hallucinations  of  hearing  appear.  Heretofore  the 
patient  may  have  thought  persons  standing  apart  were  talking 
or  whispering  about  him,  or  may  have  heard  remarks  made 
about  him  by  persons  who  passed  him  on  the  street,  but  it  is 
quite  impossible  to  tell  whether  these  were  true  hallucinations 
or  merely  falsely  interpreted  occurrences.  Now,  however,  there 
is  no  longer  any  doubt ;  the  patient  hears  actual  voices  which 
usually  make  disparaging  remarks  about  him  or  even  say 
grossly  insulting  and  vulgar  things  to  him. 

The  delusion  of  persecution,  reinforced  by  the  hallucinations 
of  hearing,  from  now  on  occupies  more  and  more  the  focus  of 
consciousness.  It  becomes  more  and  more  definite,  the  malign 
influence  is  recognized  as  an  organized  attempt  on  the  part  of 
a  secret  society,  perhaps  the  Free  Masons,  the  Jesuits,  the 
Mafia,  the  Catholic  Church,  headed  by  the  Pope.  The  agents 
of  the  society  are  always  near  him  and  the  many  annoyances 
he  suffers  are  the  results  of  their  machinations.  They  poison 
his  food,  inject  noxious  vapors  in  his  room  at  night,  send 
electric  currents  through  him  when  he  goes  to  bed,  bawl  all 
sorts  of  insults  in  his  ears  and  in  innumerable  ways  annoy  him 
and  try  to  end  his  life.  New  sensations  and  experiences  are 
explained  by  some  new  device  invented  to  torture  him — delu- 
sions of  explanation,  and  various  occurrences  going  on  about 
him  are  similarly  woven  into  the  warp  and  woof  of  his  delu- 
sional system. 

The  delusions  are  now  almost  constantly  dwelt  on  to  the 
exclusion  of  everything  else,  everything  in  life,  every  conscious 
experience,  falls  into  some  relation  with  the  central  thought, 
the  delusions  are  fully  systematized,  they  have  reached  out  their 
influences  like  the  tentacles  of  an  octopus  throughout  the  mental 
life  of  the  patient  and  exact  their  tribute  of  his  every  thought. 
During  all  this  period  of  development,  with  the  exception  of 
the  incipient  stages,  however,  there  has  been  very  little  emo- 


lOO  OUTLINES    OF    PSYCHIATRY. 

tional  abnormality.  The  only  emotional  disturbances  are  those 
naturally  incident  to  the  character  of  the  delusions  such  as 
anger,  vexation  and  the  like. 

At  first  the  patient  flees  from  his  persecutors,  going  from 
place  to  place  in  his  endeavor  to  escape,  and  finds  temporary 
relief  in  each  new  place  for  a  time  until  his  enemies  find  him 
out.  Keeping  this  up  for  a  while  until  he  finds  it  futile,  he 
endeavors  to  protect  himself  from  them  and  gets  up  all  sorts 
of  elaborate  devices,  depending,  of  course,  upon  the  character 
of  the  delusion.  The  key-hole  and  the  cracks  about  the  door 
and  windows  are  stuffed  with  papers,  the  bed  insulated  by 
having  the  legs  set  in  dishes  of  water,  the  food  carefully  tasted 
and  often  discarded.  Finally,  all  these  means  failing,  in  sheer 
desperation  and  driven  almost  frantic  by  the  continuous  perse- 
cutions, he  turns  upon  and  attacks  his  supposed  enemies. 
Magnan  speaks  of  these  three  stages  by  saying  that  at  first  he 
flees,  then  defends  himself  and  finally  attacks.  (II  fuit;  il  se 
defend ;  il  attaque. ) 

During  this  period  of  persecution  the  patient,  when  speaking 
of  his  persecutors,  at  first  uses  the  pronoun  "  they."  He  is  no 
more  specific  than  this,  but  finally  he  may  learn  exactly  who  are 
at  the  bottom  of  all  his  troubles — delusion  of  reference.  When 
he  finds  this  out  he  at  once  becomes  a  dangerous  lunatic,  liable 
at  any  time  to  acts  of  violence  of  a  homicidal  character.  These 
patients  belong  to  the  most  dangerous  class  with  whom  we 
have  to  deal,  especially  because  of  the  retention  of  their  intel- 
lectual faculties. 

After  this  condition  has  continued  indefinitely  the  third  stage 
of  the  disease  may  supervene.  The  patient  develops  ideas  of  self- 
importance.  These  ideas  may  come  about,  according  to  Magnan, 
in  one  of  three  ways.  First,  spontaneously.  Second,  through 
the  mediation  of  the  hallucinations — the  voices,  for  example, 
telling  the  patient  that  he  is  some  great  personage.  Third,  as 
the  result  of  logical  deduction — if  so  many  people,  such  pow- 
erful organizations  are  interested  in  his  downfall  he  must  in- 
deed be  some  great  personage,  rightful  heir  to  a  throne,  or 


PARANOIA    AND    PARANOID    STATES.  lOI 

inheritor  of  vast  estates.  The  development  of  this  idea  of  self- 
importance,  noble  descent  and  the  like  constitutes  the  transfor- 
mation of  the  personality  characterizing  the  third  stage  of  the 
disease. 

As  completely  as  the  delusion  of  persecution  occupies  the 
field  of  consciousness  at  this  time  and  as  thoroughly  as  it  may  be 
systematized,  we  find  in  this  as  well  as  in  the  second  stage  still 
further  evidences  of  elaboration  of  the  false  beliefs,  with  their 
projection  into  the  past  life  of  the  patient  even  as  far  back  as 
his  childhood — retrospective  falsifications.  In  the  light  of  the 
recently  acquired  facts  many  experiences  of  his  early  life,  which 
heretofore  have  seemed  mysterious,  find  their  explanation. 
His  so-called  parents  are  not  his  true  parents,  and  he  knows 
now  that  the  strange  woman  who  used  to  visit  the  house  and 
always  kept  her  face  heavily  veiled  must  have  been  the  emissary 
of  his  royal  father — retrospective  explanatory  delusion.  The 
whispered  conversation  of  his  parents  after  these  visits  had 
reference  to  him,  and  the  glances  of  the  servants  showed  that 
they  suspected  something  strange  about  him — retrospective 
delusions  of  relativity.  Often  the  patient  recalls  remarks  that 
were  never  made,  occurrences  that  never  happened  in  further 
support  of  his  false  beliefs  —  retrospective  falsification  of 
memory. 

With  the  development  and  elaboration  of  these  ideas  of  self- 
importance  the  general  attitude  and  appearance  of  the  patient 
change.  From  being  suspicious,  resentful,  irritable  and  antag- 
onistic, he  becomes  more  complacent  and  self-satisfied.  He  is 
a  great  personage  who  will  shortly  be  proclaimed  as  such  to 
the  world.  Often,  too,  he  will  tell  at  great  length  of  the 
various  methods  used  by  his  persecutors,  only  to  show  his  won- 
derful sagacity  and  prowess  in  defeating  their  ends. 

This  transformation  of  the  personality  is  the  natural  result 
of  what  has  gone  before.  We  have  traced  our  hypothetical 
case  through  the  hypochondriacal  stage  of  disorder  of  the 
somato-psychic  consciousness  and  seen  in  the  second  stage 
the  systematized  delusion  of  persecution  gradually  grow  from 


102  OUTLINES    OF    PSYCHIATRY. 

an  insignificant  beginning  to  a  state  in  which  it  dominates,  to 
the  practical  exclusion  of  everything  else,  the  consciousness  of 
the  individual.  This  delusion  involves,  in  the  main,  the  allo- 
psychic consciousness.  It  is  not  strange,  then,  that  the  remain- 
ing space  of  the  autopsychic  consciousness  should  finally  be 
encroached  upon.  (See  Chapter  VI.  Transformation  of  the 
Personality.) 

The  above  description  of  paranoia  would  indicate  a  degree 
of  regularity  and  definiteness  in  its  evolution  that  the  facts  do 
not  always  warrant.  The  disease  may  become  stationary  at 
any  point  and  the  third  stage  in  many  cases  is  never  reached. 
The  symptoms  of  the  first  stage  are  found  in  the  second,  and 
these  in  turn  in  the  third,  although  here  the  general  mood  and 
ideas  of  self-importance  may  dominate  the  picture.  The  devel- 
opment and  elaboration  of  the  disease  is  by  a  continuous  addi- 
tion rather  than  a  substitution  or  modification  of  symptoms. 

Some  authors  would  describe  a  fourth  stage  of  dementia. 
This,  however,  does  not  belong  to  the  disease  picture  proper. 
The  disease  does  not  tend  toward  marked  mental  deterioration, 
although  a  mild  degree  of  this  condition  may  supervene  in 
cases  which  have  extended  over  a  long  period  of  time,  espe- 
cially as  a  result  of  senility.  The  patients,  aside  from  the  in- 
fluence of  their  delusional  system  and  the  disorder  of  the  sen- 
sorium,  comprehend  correctly  their  environment.  They  are 
not  disoriented,  and  there  is  no  clouding  of  consciousness,  while 
their  memory  is  often  remarkable.  Their  delusions,  however, 
are  built  upon  and  result  in  reasoning  processes  which  show 
well-marked  zv.cak)icss  of  judgment,  and  this  is  especially  so 
with  reference  to  the  idea  of  self-importance  of  the  third  stage. 
In  this  sense  the  third  stage  may  be  said  to  usher  in  signs  of 
intellectual  impairment. 

Varieties. — The  disease,  instead  of  running  the  regular 
course  above  described,  may  show  certain  variations.  Aside 
from  becoming  arrested  at  any  given  point,  as  already  men- 
tioned, the  principal  one  is  the  early  appearance  of  ideas  of  self- 
importance  which   may  even   occur  contemporaneously   with 


PARANOIA    AND    PARANOID    STATES.  IO3 

those  of  persecution.  Ordinarily,  however,  the  several  varieties 
are  clinically  differentiated  because  of  the  special  content  of  the 
delusional  system. 

In  the  first  place,  paranoia  may  be  classified  on  the  basis  of 
the  presence  or  absence  of  hallucinations.  So  we  have  paranoia 
hailncinatoria,  in  which  the  hallucinations  play  a  prominent 
part  in  the  elaboration  of  the  delusional  system,  and  paranoia 
comhinatoria,  in  w^iich  hallucinations  do  not  occupy  a  promi- 
nent place  or  are  altogether  absent,  the  delusional  system  grow- 
ing on  the  basis  of  idea-association. 

The  disease  has  also  been  classified  into  early  or  original 
paranoia,  beginning  even  in  childhood,  and  late  or  acquired 
paranoia,  beginning  late  in  life.  Original  paranoia  occurs  only 
in  patients  with  very  marked  hereditary  taint,  and  as  Sander — 
who  originally  used  this  term — most  admirably  expresses  it, 
the  abnormal  condition  develops  and  unfolds  itself  in  the  same 
way  that  the  normal  mind  develops  and  unfolds  itself  in  the 
normal  individual.  Acquired  paranoia,  on  the  other  hand, 
develops  in  an  individual,  who,  except  for  his  hereditary  taint, 
may  appear  to  be  a  normal  person.  While  in  late  paranoia 
there  is,  as  we  have  seen,  a  transformation  of  the  personality, 
a  change  in  the  individual  wrought  by  the  disease  process ;  in 
original  paranoia  there  is  not  a  transformation  but  an  unfold- 
ing of  a  personality  which  is  from  the  beginning  pathological. 

The  querulous  or  litigious  variety  occupies  a  position  midway 
between  the  original  and  acquired,  and,  like  the  original  hallu- 
cinations, do  not  play  a  prominent  part  in  its  evolution,  and 
also  like  the  original,  the  delusions  often  contain  elements  of 
truth  and  often  develop  on  the  basis  of  some  actual  occurrence, 
more  particularly  the  loss  of  some  law  suit.  They  are  notable 
not  only  because  of  t^lieir  apparent — in  fact  their  real — adher- 
ence to  facts,  but  for  their  convincing  character. 

Bianchi  would  classify  the  disease  upon  the  basis  of  what  he 
terms  the  primitive  emotions — suspicion,  ambition,  love — which 
determine  the  three  classic  varieties :  the  persecutory,  the  ambi- 
tious or  proud,  and  the  erotic.     He  says  on  this  point : 


I04  OUTLINES    OF    PSYCHIATRY. 

"  In  paranoia  the  fundamental  emotions,  which  are  also  an 
expression  of  the  altered  kinesthesis,  are  emotions  of  a  primitive 
character,  such  as  suspicion,  vanity,  pride  and  fear — fear  of 
injury  and  destruction,  desire  of  exaltation  and  of  grandeur  of 
one's  own  ego.  Therein  lies  the  reason  of  the  egocentric  atti- 
tude of  the  paranoic  subject  (Specht).  These  primitive  emo- 
tive states,  intrinsic  to  the  personality  and  proportioned  differ- 
ently in  different  men,  determine  currents  and  orders  of  ideas 
and  actions  in  the  evolution  of  the  personality,  which  succeed, 
in  various  ways,  in  protecting  or  expanding  the  personality  in 
a  rigorously  logical  fashion.  When  those  emotive  states  ex- 
ceed the  normal  measure  in  intensity  and  persistence,  they 
exercise  an  absolute  dominion  over  the  consciousness,  until, 
through  their  having  once  assumed  government  over  the  senses 
and  the  intellect,  there  is  an  alteration  of  the  perception  and 
the  apperception  processes  that  insure  normal  relations  between 
the  individual  and  his  environment." 

A  very  practical  classification  of  the  disease  is  based  upon 
the  prevalence  of  grandiose  ideas.  Thus  the  type  of  disease 
such  as  I  have  described,  in  which  the  delusions  of  persecution 
are  the  most  prominent  features,  would  be  classed  as  perse- 
cutory paranoia,  while  those  in  which  grandiose  ideas  pre- 
dominated would  be  classed  as  expansive  paranoia.  This  latter 
group  includes  that  host  of  unbalanced  dreamers  who  are  fre- 
quently known  as  "  cranks,"  and  who  may  be  further  classified 
on  the  basis  of  the  content  of  their  delusional  system  into 
inventive,  reformatory,  religious  and  erotic  varieties.  These 
patients  have  made  some  wonderful  invention,  are  destined  to 
carry  on  great  reforms,  are  the  vicegerent  of  God,  or  believe 
themselves  beloved  by  some  royal  person.  In  these  cases  the 
idea  of  self-importance  quite  obscures  the  persecutory  ideas, 
which,  if  they  are  present  at  all,  become  a  negligible  quantity, 
while  in  many  cases  they  are  not  present  in  the  true  sense  of 
the  term.  A  reformatory  paranoiac  may  be  prevented  from 
doing  as  he  wishes  by  the  civil  authorities,  whereupon  he  be- 
lieves himself  persecuted,  but  this  is  not  a  true  delusion  of 


PARANOIA    AND    PARANOID    STATES.  I  OS 

persecution  in  the  sense  this  term  has  been  used  in  describing 
paranoia.  When  such  patients  are  interfered  with  they  usually 
resent  it  and  often  rebel.  They  are  then  designated  as  perse- 
cuted persecutors. 

This  whole  anomalous  group  of  paranoiac  psychoses  devel- 
oping upon  a  markedly  predisposed  background,  in  individuals 
of  a  strong  hereditary  taint,  has  been  designated  by  the  French 
as  the  insanity  of  degenerates. 

Course  and  Prognosis. — True  paranoia  is  never  recovered 
from.  The  insanity  of  degenerates  is  not  infrequently  inter- 
rupted in  its  course  by  intermissions  of  variable  length ;  in  fact, 
Magnan  says  recovery  often  takes  place. 

Differential  Diagnosis. — The  principal  disease  with  which 
paranoia  is  apt  to  be  confused  is  dementia  precox  paranoides. 
The  principle  of  differentiation  rests  with  the  occurrence  in  this 
form  of  dementia  precox  of  signs  ^f  deterioration  foreign  to 
the  classical  type  of  paranoia.  The  deterioration,  however, 
may  not  be  very  apparent  in  the  early  stages  and  time  may  be 
required  to  make  the  differentiation. 

Paranoid  states  occur  in  many  other  psychoses — see  below. 

Pathology. — Strictly  speaking,  paranoia  has  no  pathology. 
The  hereditary  taint  is  sometimes  manifested  by  errors  of  de- 
velopment— giving  rise  to  malformations  generally  known  as 
stigmata  of  degeneration;  abnormalities  in  the  course  of  the 
cerebral  vessels  and  asymmetries  and  abnormalities  of  gyral 
configuration  have  been  noted. 

Treatment. — There  is  no  medical  treatment  for  this  disease. 
In  general  it  may  be  said  that  these  cases  require  to  be  cared 
for  throughout  their  lives  in  an  institution.  They  are  pecu- 
liarly unfit  to  live  in  the  outside  world,  and  sooner  or  later,  as 
a  result  of  their  general  conduct  or  some  overt  act,  are  com- 
mitted as  insane. 

The  paranoiac  character  differs  in  different  persons  perhaps 
as  much  as  the  normal  character.  While  many  paranoiacs  are 
dangerous  and  should  be  kept  confined,  others  show  no  dan- 
gerous tendencies,  are  perhaps  naturally  timid  and  never  would 


I06  OUTLINES    OF    PSYCHIATRY. 

do  any  harm,  while  still  others  may  become  resigned.  While 
many  of  these  latter  class  may  often  get  on  for  a  time,  at 
least  outside  of  an  institution,  they  should  be  kept  under  con- 
stant obsen^ation,  so  that  changes  in  their  delusional  system 
and  in  their  character  of  reaction  can  be  noted. 

Paranoid  States, 

The  adjective  paranoid  or  paranoiac,  meaning  like  paranoia, 
is  applied  to  mental  states  superficially  simulating  paranoia, 
specifically  mental  states  showing  more  or  less  systematized 
delusions  of  persecution  and  hallucinations  of  hearing.  Many 
different  mental  diseases  may  present  paranoid  conditions  and 
not  infrequently  paranoid  states  are  met  with  that  are  quite 
difficult  to  definitely  diagnose  so  that  the  term  is  in  frequent 
use. 

These  paranoid  states  are  met  with  in  dementia  precox, 
paresis,  the  toxic  psychoses,  the  psychoses  of  the  involution 
period,  manic-depressive  insanity,  and  in  fact  in  practically 
all  of  the  various  types  of  mental  disease.  In  general  these 
states  are  transitory  and  while  presenting  the  various  symp- 
toms of  the  disease  in  which  they  occur  are  usually  further 
characterized  by  a  less  stable  and  coherent  organization  of  the 
delusional  system.  The  paranoid  states  that  occur  in  hypo- 
mania  are  particularly  difficult  to  diagnose,  while  those  which 
follow  other  psychoses,  especially  the  toxic  and  infectious, 
such  as  alcohol,  cocaine,  typhoid,  are  particularly  persistent, 
often  lasting  for  many  months.  These  conditions  have  given 
origin  to  the  term  secondary  paranoia. 

The  question  of  whether  or  no  there  exists  an  acute  paranoia 
is  still  undecided.  The  existence  of  paranoid  states  in  some 
of  the  acute,  curable  psychoses  has  in  the  past  undoubtedly 
been  largely  responsible  for  the  belief  in  an  acute  form  of  the 
disease  and  the  Germans  have  long  described  such  a  form 
under  the  name  of  Wahnsinn.  Later,  however,  since  the 
true  significance  of  paranoid  states  has  been  better  under- 
stood  and  their  occurrence   in   the  acute,  curable   psychoses 


PARANOIA    AND    PARANOID    STATES.  ID/ 

known,  there  are  still  those  who  believe  in  an  acute,  curable 
paranoia  different  from  any  of  these  conditions. 

Wahnsinn  or  more  fully  hallucinatorische  Wahnsinn^  as  it 
is  called  is  described  as  a  psychosis  presenting  marked  dis- 
turbance of  the  sensorium — hallucinations — which  leads  to  the 
development  of  delusions  which  are  dependent  upon  them  and 
have  only  a  loose  connection  with  one  another,  changing  with 
the  shifting  character  of  the  hallucinations.  This  condition 
exists  with  clear  consciousness  and  also  a  more  pronounced 
disorder  of  affect  than  in  paranoia  proper.  Kraepelin  would 
classify  the  depressed  forms  as  varieties  of  involution  melan- 
cholia, the  exalted  cases  as  paranoid  states  of  hypomania,  and 
certain  other  conditions  following  alcohol  and  cocaine  as  de- 
pendent on  these  poisons — the  cases  I  have  previously  men- 
tioned as  often  spoken  of  as  secondary  paranoia.  The  diag- 
nosis would  have,  of  necessity,  to  be  made  with  great  care  and 
by  the  method  of  exclusion. 

^  The  German  term  Wahnsinn  is  used  only  because  it  has  no  exact 
English  equivalent. 


CHAPTER    IX. 

MANIC-DEPRESSIVE    PSYCHOSES. 

In  the  older  psychiatry  a  large  number  of  the  cases  were 
classified  as  mania  and  melancholia.  Practically  all  excited 
and  exalted  cases  were  included  under  the  designation  of 
mania  while  all  the  depressed  cases  were  classed  as  melan- 
cholia. These  two  psychoses  were  generally  conceded  to  be 
recoverable,  the  percentage  of  recoveries  being  figured  as 
high  as  ninety  by  some.  Then  again  certain  other  cases 
were  recognized  as  having  a  periodic  tendency  in  which  at- 
tacks of  mania  and  melancholia  followed  each  other  in  regular 
succession.  These  cases  were  conceded  to  be  incurable  and 
the  anomalous  circumstance  was  recognized  of  an  incurable 
disease  being  constituted  of  phases  each  one  of  which  con- 
sisted, apparently,  of  an  attack  of  the  most  curable  form  of 
mental  disorder. 

This  condition  of  affairs  continued  until  Kraepelin  came 
forward  with  the  key  to  the  mystery  by  demonstrating  that 
circular  insanity  manifested  certain  fundamental  symptoms 
which  were  characteristic  of  mania  and  melancholia  and  also 
that  mania  and  melancholia  rarely  occurred  in  isolated  attacks 
but,  on  the  contrary,  during  some  part  of  their  course  ex- 
hibited symptoms  of  the  opposite  condition — mania  of  melan- 
cholia and  melancholia  of  mania.  This  analysis  gave  rise 
to  the  conception  of  a  single  disease  of  which  mania,  melan- 
cholia, and  circular  insanity  were  so  many  different  manifesta- 
tions, and  to  this  disease  Kraepelin  gave  the  name  of  manic- 
depressive  insanity — the  name  indicating  the  principal  phases 
of  its  occurrence. 

Etiology. — The  principal  cause  is  hereditary  taint,  and  it 
is  noteworthy  that  this  disease  is  often  found  in  families,  the 

io8 


MANIC-DEPRESSIVE   INSANITY.  IO9 

constitutional  condition  as  the  basis  on  which  it  develops 
appearing  to  be  directly  transmitted.  Although  concomitant 
conditions  of  stress  often  occur  with  the  first  and  even  subse- 
quent attacks  and  appear  to  condition  them,  still  these  attacks 
are  much  more  noticeable  for  their  apparent  lack  of  cause, 
their  spontaneous  onset  thus  evidencing  their  deep-seated  con- 
stitutional origin. 

General  Symptomatology. — Before  proceeding  to  a  de- 
scription of  the  different  forms  of  manic-depressive  insanity  it 
may  be  well  to  pause  for  a  few  moments  and  study  the  fol- 
lowing  diagrams   which   endeavor   to   set    forth   graphically 


«    DECReASE:0     PSYCHOMOTOR     ACTIVITY 


«    INCREASED  •' 

=    EMOTIONAL.       EXALTATION 


=  EMOTIONAL      DEPRESSION 


how  the  various  symptoms  of  the  disease  may  be  combined. 
If  note  is  first  made  of  the  general  way  of  representing 
the  opposed  conditions  of  the  psychomotor  and  emotional 
states  what  follows  will  be  perfectly  clear  without  further 
explanation. 

In  describing  this  disease  the  two  principal  stages — the 
manic  and  the  depressive — will  be  described  first,  then  the 
various  forms  of  periodic  insanity,  and  finally  certain  irreg- 
ular and  unusual  combinations  of  symptoms  known  as  the 
mixed  states  will  receive  attention. 

Manic  Stage. 

This   stage  of   manic-depressive   insanity   manifests   itself 

by  three  cardinal  symptoms,  viz.,   (i)   Flight  of  idea^.     (2) 

Psychomotor  excitement.     (3)  Emotional  excitement.     These 

symptoms  may  manifest  themselves  in  any  degree  of  severity 


no 


OUTLINES    OF    PSYCHIATRY. 


and  the  content  of  consciousness  may  vary  widely  in  different 
cases.     For  purposes  of  description  it  is  convenient  to  divide 


BASE    L/NE    =      NORMAL 

/     =      HYPOMANIA 

Z    =  ACUTE   MANIA 

3      •  HYPERACUTE  MANIA 


^^ 


BASE  LINE=  NORMAL 

/  c   SIMPLE    RETARDATION 
Z    --   ACUTE    MELANCHOLIA 
»5  =  STUPOROUS    MCLANCHOL/A 


RECURRENT     MANIA 


RECURRENT    MELANCHOLIA 


MANIC-DEPRESSIVE    INSANITY. 


II  I 


mania  into  three  grades  in  accordance  with  its  severity. 
These  grades  also  answer  very  well  to  the  clinical  types  met 
with  although  it  must  of  course  be  understood  that  the  mania 


C/RCULAR     INSANITY 


/iLTE:RNATlNG     /NSANITY' 

may  be  of  any  degree  of  severity  and  that  in  a  given  case  it 
may  manifest  itself  in  different  degrees  at  different  times 
during  the  same  attack. 

Hypomania  is  the  term  applied  to  the  mildest  of  these 
degrees  of  maniacal  excitement.  Here  we  have  in  the  sim- 
pler cases  a  disorder  of  the  process  of  thinking  rather  than 
in  the  content  of  thought.     The  separate  ideas  and  even  acts 


fiLTERN^TING    INSf^NITY   OF    DOUBLE    PHASE 

may  not  be  unusual  and  yet  when  taken  in  their  ensemble 
are  seen  to  be  distinctly  abnormal.  The  example  given  by 
Mercier  illustrates  this  very  well.  He  says  of  a  case  of  this 
sort  "  Its  subject  rises  early,  full  of  schemes  of  business  or 


112 


OUTLINES   OF   PSYCHIATRY. 


INSANITY   or  DOUBLE   FORM 


MANtAC/\L      STUPOR 


AGITATED      DEPRESSION 


MIXED      STATES     OCCURRING     ^SPECIALLY    AT 


THE   TRAA/SIT/O/V   FROM  ONE  STAGE  TO  ANOTHEH 

pleasure.  He  fusses  noisily  about  the  house,  indifferent  to 
his  disturbance  of  other  people's  slumbers.  He  is  very  im- 
patient of  delay,  he  cannot  wait  a  minute  for  anything  that 
he  wants,  and  if  it  is  not  forthcoming  on  the  instant,  he  flies 
into  a  rage.  The  course  of  the  post  is  not  expeditious  enough 
for  him.  He  sends  his  letters  by  telegraph,  and  his  letters  are 
extraordinarily  numerous.  They  would  be  numerous  in  any 
case,  but  their  number  is  doubled,  and  more  than  doubled,  by 
the  frequent  changes  of  his  mind,  and  by  the  impulsiveness 


MANIC-DEPRESSIVE    INSANITY.  II  3 

with  which  he  acts  upon  every  passing  whim.  He  deter- 
mines to  make  some  purchase,  probably  a  very  unnecessary 
one,  but  one  for  which  he  can  adduce  twenty  plausible  reasons, 
and  he  writes  to  tell  his  solicitor  that  he  will  call  the  next 
morning.  Scarcely  is  the  letter  posted  when  he  sees  that  he 
will  attain  his  object  more  quickly  by  asking  his  solicitor  to 
lunch.  He  telegraphs  accordingly.  Before  his  messenger 
returns,  it  occurs  to  him  that  he  had  better  ask  the  vendor  to 
lunch  also.  Another  telegram  is  despatched,  and  since  he 
cannot  entertain  more  than  one  visitor  at  his  club,  another 
must  be  sent  to  the  solicitor  to  announce  the  change  to  a  hotel. 
Then  he  remembers  that  he  has  been  drawing  heavily  of  late 
on  his  banking  account,  and  that  he  may  not  have  the  neces- 
sary funds  available.  Another  telegram  to  the  bank.  But 
if  there  are  insufficient  funds  in  the  bank,  he  will  have  to 
sell  stock  to  raise  the  funds;  another  telegram  to  his  broker. 
Then  he  determines  that  it  will  be  better  to  pledge  the  stock 
to  the  bank  rather  than  to  sell  it.  More  telegrams  to  the 
broker  and  to  the  bank.  The  broker  won't  like  the  contra- 
dictory orders — never  mind;  ask  him  to  dinner — ask  them 
all  to  dinner.  Put  off  the  lunch  and  have  a  dinner  instead, 
and  ask  the  solicitor,  the  vendor,  the  banker  and  the  broker. 
Yes,  and  why  not  Smith  and  Jones  and  Robinson  as  well? 
More  telegrams;  and  then,  since  two  out  of  the  three  of  the 
invited  guests  decline,  the  whole  thing  is  postponed,  also  by 
telegraph.  Meantime,  in  the  intervals  of  telegraphing,  his 
hands  have  been  full.  He  has  been  constantly  ringing  the 
bell  and  giving  orders — giving  them,  modifying  them,  and 
countermanding  them — constantly  wanting  something  fresh, 
running  up  and  down  stairs,  writing  letters,  haranguing  this 
person  and  that,  flying  into  a  rage  upon  the  slightest  opposi- 
tion, tearing  the  bell  down  on  the  slightest  delay,  and  talking 
almost  incessantly." 

In  this  example  the  subject's  acts  might  almost  all  of  them 
be  considered   as   normal   with   the   exception   of   those   due 
to  undue  irritability  or  anger.      Aside  from  these  each  act  is 
9 


114  OUTLINES    OF    PSYCHIATRY. 

consistently  directed  to  some  definite  aim.  The  disorder  is 
not  in  the  content  of  thought  but  in  the  process  of  thinking 
and  the  disorder  of  process  manifests  itself  by  a  rapid,  too 
frequent  change  of  direction. 

In  this  condition  we  see  a  patient  constantly  active,  busying 
himself  about  one  thing  and  another,  talking  continuously 
meanwhile,  often  in  a  loud  and  rather  boisterous  manner, 
while  emotionally,  exaltation  is  manifested  by  good  humor, 
a  smiling  countenance  and  increased  self  esteem,  punctuated 
mayhap  by  attacks  of  irritability  or  impulsive  anger  with  little 
or  no  cause.  His  confidence  in  his  own  ability  is  unqualified 
and  is  shown  in  the  outlining  of  all  manner  of  schemes  of 
work,  investments,  business  enterprises  and  the  like.  Flight 
of  ideas  is  marked  though  not  of  high  degree,  the  conversa- 
tion changing  at  frequent  intervals  from  subject  to  subject  and 
the  activities  show  a  like  characteristic,  there  being  no  con- 
sistent effort  directed  toward  any  one  aim  for  any  length  of 
time.  Letters  are  often  written  in  great  numbers  and  their 
contents  exhibit  the  same  characteristics  as  do  the  speech  and 
conduct.  The  patient  is  fully  oriented,  there  is  no  clouding 
of  consciousness  nor  delusions.  In  spite,  however,  of  the 
lucidity  and  apparent  abundance  of  energy  the  real  efficiency 
if  the  indivdual  is  greatly  reduced  largely  because  of  the  lack 
of  consecutiveness  in  application.  Ofttimes  the  picture  is 
complicated  by  the  addition  of  symptoms  due  to  alcoholic  in- 
dulgence which  is  very  common  in  patients  in  this  condition, 
many  of  whom  show  marked  moral  delinquencies  and  because 
of  their  lucidity  and  facility  of  expression  often  elude  the 
authorities,  being  at  once  discharged  after  examination  when 
apprehended  because  of  supposed  insanity. 

The  next  grade  of  maniacal  excitement  presents  perhaps 
the  most  characteristic  picture  of  this  stage  and  is  the  classical 
condition  of  acute  mania. 

In  this  condition  the  flight  of  ideas  is  well  marked  even 
to  the  point  oftentimes  that  the  train  of  thought  is  apparently 
quite  incoherent.     Distractibility  is  a  prominent  feature  and 


MANIC-DEPRESSIVE    INSANITY.  I  I  5 

the  almost  constant  flow  of  ideas  frequently  refer  to  some- 
thing seen  or  heard  in  the  environment.  A  tendency  to  rhyme 
is  not  infrequently  present  and  words  heard  by  the  patient  are 
often  woven  into  or  form  the  starting  point  for  these  rhymes 
which  may  be  nothing  more  than  a  string  of  words  of  similar 
sound  (clang  association).  It  is  quite  remarkable  how  such 
a  patient  who  is  apparently  paying  no  heed  to  what  is  going 
on  about  him  will  catch  a  chance  word  or  phrase  uttered  by 
some  one,  perhaps  a  considerable  distance  away,  and  introduce 
it  into  the  stream  of  his  conversation. 

Consciousness  may  be  more  or  less  clouded  and  there  is 
often  some  disorientation;  this  is  especially  noticeable  for 
persons.  This  condition,  however,  is  largely  if  not  wholly 
due  to  the  disorder  of  attention.  The  patient  does  not  ade- 
quately perceive  the  environment,  therefore  a  comprehensive 
idea  of  it  is  not  obtained  and  in  the  rapid  and  transitory  sur- 
vey a  superficial  quality  is  often  emphasized — perhaps  some 
resemblance — and  the  person  or  object  is  mistaken.  In  this 
way  the  nurses  and  physicians  are  called  by  the  names  of 
friends  or  relatives  and  the  surroundings  are  said  to  be  those 
of  some  place  the  patient  has  been  in  the  past.  These  errors 
are,  however,  often  not  firmly  fixed  and  the  patient  may  cor- 
rect them  spontaneously  at  times. 

The  disorders  of  attention,  flight,  distractibility  are  all  ele- 
ments in  producing  a  content  of  consciousness  in  which  all 
ideas  have  the  same  value.  Nothing  is  attended  to  long 
enough  to  give  it  an  importance  greater  than  other  experi- 
ences, ideas  are  voiced  first  about  this  subject  and  then  about 
that,  the  patient  changing  from  subject  to  subject  without 
attaching  more  importance  to  one  than  to  another,  without 
being  led  by  one  idea  to  the  exclusion  of  others — there  is  a 
leveling  of  ideas — all  ideas  reach  the  same  level  of  importance 
in  consciousness. 

Hallucinations  are  not  infrequent.  They  are  usually  ele- 
mentary in  character,  simple  and  transitory. 

Delusions  may  also  be  present  but  are  not  fixed  but  change- 


Il6  OUTLINES    OF    PSYCHIATRY. 

able,  coming  and  going.  They  are  usually  of  a  grandiose 
character,  but  lack  the  element  of  extreme  improbability  or 
absolute  ridiculousness  often  seen  in  conditions  of  dementia. 
Occasionally  a  paranoid  state  develops  with  quite  stable  de- 
lusions of  persecution.  This  condition  is  difficult  to  diagnose 
especially  if  the  excitement  is  of  a  mild  character  as  in  hypo- 
mania. 

The  psychomotor  activity  is  constant.  There  seems  to  be 
absolute  inability  to  keep  quiet — pressure  of  activity — the 
patient  runs  and  jumps,  turns  somersaults,  waves  the  arms 
about,  tears  up  his  clothing,  destroys  plants,  breaks  furniture, 
howls  and  yells  all  night  long,  going  almost  absolutely  with- 
out sleep,  often  showing  marked  sexual  excitement.  The 
excitement  is  so  great  that  these  patients  do  not  even  take 
time  to  eat,  food  placed  before  them  is  perhaps  tasted  and 
then  thrown  about  like  everything  else  that  comes  in  their  way, 
so  that  emaciation  soon  becomes  marked.  In  less  marked 
degrees  of  excitement,  however,  it  is  common  for  this  class 
of  patients  to  gain  in  weight. 

The  emotional  exaltation  is  marked  and  shown  by  boister- 
ous laughter  and  remarks  showing  exaggerated  ideas  of  self 
esteem  and  personal  prowess.  The  patients  are  apt  to  be  very 
irritable  in  this  condition  and  are  constantly  fomenting  trouble 
of  some  sort  on  the  wards  where  they  are  confined. 

The  third  grade  of  maniacal  excitement  is  merely  a  more 
aggravated  form  of  the  condition  just  described  and  may  be 
called  delirious  mania. 

In  this  condition  the  flight  is  so  great  as  to  amount  to  almost 
complete  incoherence,  the  activity  is  unremitting,  conscious- 
ness is  more  clouded  and  hallucinations  are  more  in  evidence. 
The  condition  leads  to  great  exhaustion  and  physical  deple- 
tion, and  it  frequently  happens  that,  as  a  result  of  slight 
scratches  and  bruises  obtained  during  the  period  of  great 
motor  restlessness,  and  which  are  not  allowed  to  be  properly 
dressed,  local  areas  of  suppuration  develop,  so  that  a  mild 
septicemia  with  some  temperature  complicates  the  picture.    Ex- 


MANIC-DEPRESSIVE    INSANITY.  11/ 

haustion  and  toxemia  are  both  now  added,  the  clouding  of  con- 
sciousness becomes  profound,  a  true  delirium  takes  the  place 
of  the  flight,  marked  by  absolute  incoherence  and  complete 
confusion  {secondary  confusion)  with  transitory  and  elemen- 
tary sensory  falsifications. 

The  acute  delirious  mania,  which  used  to  be  described  as 
always  and  invariably  fatal,  was  probably  in  a  certain  propor- 
tion of  cases  an  aggravated  form  of  the  manic  stage  of  manic- 
depressive  insanity.  It  is  probable,  however,  that  it  was  more 
usually  an  acute  psychosis  associated  with  some  serious, 
though  often  unrecognized,  condition  of  the  internal  organs, 
as  i.  e.,  an  acute  nephritis  or  pneumonia.  It  can  be  readily 
seen  how  such  conditions  might  be  overlooked  in  patients  so 
wildly  excited  and  autopsies  of  late  have  tended  to  show  that 
this  was  the  case. 

Depressive  Stage. 

This  stage  of  manic-depressive  insanity  also  manifests  itself 
by  three  cardinal  symptoms,  each  one  of  which  is  opposed  to 
the  corresponding  symptom  of  the  manic  stage,  viz.,  i.  Diffi- 
culty of  thinking.  2.  Psychomotor  retardation.  3.  Emotional 
depression. 

This  set  of  symptoms  may,  as  in  the  manic  set,  manifest 
themselves  with  any  degree  of  severity — and  as  for  that  stage 
it  is  convenient  to  describe  them  in  three  different  grades. 

The  mildest  grade  of  depression  is  called  simple  retardation. 
The  word  retardation  here,  as  frequently,  refers  not  only  to 
psychomotor  retardation  but  to  the  difficulty  in  thinking,  as 
the  two  phenomena  are  in  reality  similar  manifestations  in 
different  spheres.  This  designation — simple  retardation — is 
significant,  too,  because  the  emotional  state  is  not  indicated 
and  as  a  matter  of  fact  is  of  less  importance  diagnostically 
than  the  retardation. 

These  patients  move  slowly,  speak  slowly  and  in  a  low  tone, 
often  only  just  above  a  whisper,  and  by  preference  answer 
questions  in  monosyllables.     They  sit  about  with  folded  hands 


Il8  OUTLINES    OF    PSYCHIATRY. 

doing  nothing;  they  are  incapable  of  effort  of  any  sort,  even 
reading  is  not  indulged  in,  for,  aside  from  the  effort  required, 
what  is  read  is  not  assimilated,  ideas  are  not  called  up  by  what 
is  read,  and  the  continuous  effort  is  impossible. 

Emotionally  the  patient  is  depressed  but  the  depression  may 
not  be  at  all  marked  and  in  these  cases  the  facial  expression 
fails  to  indicate  it  at  all.  They  often  realize  their  mental 
invalidism  and  are  distressed  by  it.  Consciousness  is  not 
clouded  and  they  are  fully  oriented. 

The  next  grade  of  depression  is  the  ordinary  acute  uielcm- 
cholia.  This  condition  of  depression,  however,  may  be  further 
qualified  by  the  adjective  depressive — acute  depressive  melan- 
cholia— to  indicate  that  it  is  a  stage  of  manic-depressive  insan- 
ity and  to  distinguish  it  from  involution  melancholia,  which  is 
an  affective  melancholia.  In  the  former  the  retardation  is  the 
distinctive  feature;  in  the  latter  the  emotional  depression. 

In  this  condition  the  three  cardinal  symptoms  of  depression 
are  manifested  in  a  much  more  pronounced  way.  The  patients 
are  inactive,  sitting  by  themselves,  showing  little  or  no  ten- 
dency to  associate  with  others,  their  movements  are  very  slow 
and  deliberate,  and  it  often  takes  a  considerable  time  to  initiate 
them  (initial  retardation).  The  speech  is  similarly  affected; 
it  is  slow,  preferably  monosyllabic,  and  often  almost  inaudible. 
Initial  retardation  is  very  noticeable  here  also.  The  emotional 
depression  is  profound  and  is  indicated  in  the  attitude  which 
is  in  general  one  of  flexion,  the  hands  lie  limp  in  the  lap,  the 
head  is  inclined  forward  so  that  the  chin  rests  on  the  breast, 
the  shoulders  are  also  bent  forward  and  the  whole  attitude, 
together  with  the  facial  expression,  indicates  sadness. 

In  this  condition  delusions  are  the  rule  and  are  typically 
self-accusatory.  The  patients  think  themselves  responsible  for 
all  the  sin  and  wickedness  or  privation  and  suffering  in  the 
world ;  they  are  the  cause  of  the  unfortunate  condition  of  their 
fellow  patients,  have  themselves  committed  some  great  sin, 
and  are  forever  and  absolutely  lost.  They  very  often,  too, 
have  hypochondriacal  ideas,  think  they  have  some  incurable 


MANIC-DEPRESSIVE    INSANITY.  II9 

disease,  that  their  organs  are  decayed,  something  has  happened 
to  their  brains,  their  bowels  are  stopped  up  and  the  Hke. 

The  changes  in  the  organic  sensations  produce  pecuhar  feel- 
ings which  are  variously  interpreted,  often  leading  to  more  or 
less  disaggregation  of  the  personality,  the  strange  feelings  being 
supposed  to  indicate  mysterious  changes  going  on  within  the 
body.  A  patient  will  keep  going  to  the  looking-glass  to  look 
at  her  eyes,  averring  that  they  look  like  cat's  eyes,  that  they 
are  cat's  eyes.  It  is  only  a  step  from  this  condition  to  a  belief 
in  the  complete  transformation  of  the  personality  or  a  belief 
that  another  being  has  taken  possession  of  their  body  and  ex- 
presses itself  in  their  acts. 

Hallucinations  also  occur,  but  consciousness  is  usually  quite 
clear  and  the  patient  may  be  fully  oriented.  However,  a 
marked  degree  of  clouding  is  not  uncommon  and  hallucinations 
and  delusions  may  be  the  outcome  of  insufficient  perception  of 
the  environment,  as  in  the  instance  previously  cited  of  the 
patient,  who,  profoundly  depressed,  was  so  wrapped  up  in  her 
sufferings  that  she  did  not  perceive  the  nurse  bring  the  tray 
of  food  and  set  it  down  beside  her  and  when  her  attention  was 
called  to  it  thought  it  must  have  been  placed  there  by  some 
mysterious  agency. 

Physically  there  is  almost  invariably  present  constipation, 
coated  tongue,  indicanuria,  poor  appetite,  loss  of  weight,  with 
disturbed  sleep  and  poor  circulation,  with  cold  and  often  blue 
extremities. 

The  third  and  most  marked  grade  of  depression  is  depressive 
stupor.  In  this  condition  the  retardation  has  proceeded  to 
such  an  extent  that  the  patient  does  not  speak.  He  lies  in  bed, 
often  for  days  at  a  time,  in  this  almost  absolutely  inactive  state, 
having  to  be  fed  and  his  every  want  ministered  to. 

During  this  condition  of  great  retardation  the  patient  may 
be  suffering  from  the  most  dreadful  delusions  and  hallucina- 
tions. This  condition  of  mind  may  be  shown  by  an  anxious 
expression  of  countenance,  but  its  details  can  only  be  learned 
after  the  patient  recovers  sufficiently  to  describe  them.     The 


I20  OUTLINES    OF    PSYCHIATRY. 

hallucinations  present  themselves  to  the  patient  as  in  a  dream 
and  there  is  a  considerable  degree  of  clouding  of  consciousness 
present,  to  some  extent  due  to  the  absorption  of  the  patient's 
attention  by  these  hallucinations. 

This  condition  of  stupor  is  common  in  the  course  of  depres- 
sive melancholia  and  occurs  as  an  episode  more  often  than  as 
a  distinct  form  of  the  disease. 

The  Periodical  Psychoses. 

Under  this  head  are  included  those  forms  which  have  been 
severally  described  as  recurrent  mania,  periodic  mania,  inter- 
mittent mania,  recurrent  melancholia,  insanity  of  double  form, 
alternating  insanity,  etc. 

All  of  these  insanities  are  merely  different  manifestations 
of  manic-depressive  insanity,  the  manic  and  depressive  stages 
being  represented  in  various  relations,  often  separated  by  a 
lucid  interval.  Thus  recurrent  mania  would  be  recurrent 
attacks  of  the  manic  stage  separated  by  lucid  interv-als,  simi- 
larly for  recurrent  melancholia,  while  alternating  insanity 
would  consist  of  manic  and  depressive  attacks,  each  followed 
by  a  lucid  interval ;  circular  insanity,  on  the  other  hand,  being 
cycles  of  manic  and  depressive  stages  without  intervals  of 
separation,  while  insanity  of  double  form  would  consist  of 
cycles  of  excitation  and  depression,  each  cycle  followed  by  a 
lucid  interval.  Other  varieties  might  be  described,  but  it 
sufifices  to  say  that  the  three  stages — manic,  depressive  and 
lucid  interval — may  be  combined  in  any  possible  way,  and  that 
further  in  a  given  case  any  degree  of  the  manic  or  depressive 
stages  may  occur. 

The  Mixed  States. 

The  mixed  states  are  forms  of  manic-depressive  insanity  in 
which  the  three  cardinal  symptoms  of  the  manic  and  depressive 
stages  are  mixed  so  that  the  resulting  state  is  not  either  one. 
The  best  recognized  are:  (i)  Maniacal  Stupor,  (2)  Agitated 
Depression,  and  (3)  Unproductive  Mania.  It  will  suffice  to 
merely  mention  the  symptoms  of  these  three  groups  and  to  say 
that  still  others  are  possible. 


MANIC-DEPRESSIVE   INSANITY.  121 

Maniacal  Stupor. — Emotional  exaltation,  decreased  psycho- 
motor activity,  difficulty  of  thinking. 

Agitated  Depression. — Emotional  depression,  increased  psy- 
chomotor activity,  flight  of  ideas. 

Unproductive  Mania. — Emotional  exaltation,  increased  psy- 
chomotor activity,  difficulty  of  thinking. 

Still  the  possibilities  are  not  exhausted.  It  is  quite  uncom- 
mon to  see  any  one  of  the  conditions  already  described  continue 
pure  from  the  commencement  to  the  end  of  the  attack.  In  the 
manic  stage  symptoms  of  depression  not  infrequently  crop  up 
and  occupy  the  field  temporarily,  while  during  the  depressive 
stage  it  is  quite  as  common  to  note  transitory  periods  of  excite- 
ment. Then  it  is  quite  common  for  manic  attacks  to  be  pre- 
ceded by  a  longer  or  shorter  attack  of  depression,  and  some- 
times such  a  period  of  depression  follows,  not  infrequently  but 
partial  depression,  of  the  type  of  unproductive  mania.  The 
depressive  stage  shows  similar  variations,  more  particularly 
is  it  followed  by  a  short  period  of  exaltation.  Then,  again,  at 
any  stage  of  the  disease  a  mixed  state  may  crop  up  for  a  time, 
so  that  we  may  see  during  the  course  of  the  manic  stage  psycho- 
motor retardation  occur  or  during  the  stage  of  depression 
emotional  exaltation  may  develop,  while  in  the  various  forms 
of  periodical  insanity  it  is  quite  the  rule  to  find  these  mixed 
states  at  the  transition  places  from  one  stage  to  another,  all  of 
the  symptoms  of  one  stage  not  equally  and  contemporaneously 
graduating  into  their  opposites.  Thus  during  the  course  of 
a  circular  insanity  the  affect  may  change  from  depression  to 
exaltation  before  the  psychomotor  retardation  has  given  place 
to  increased  psychomotor  activity,  thus  producing  a  temporary 
mixed  state. 

Course  and  Prognosis. — The  individual  attacks  vary  in 
duration  from  a  few  days  to  several  months,  some  attacks, 
however,  being  greatly  prolonged.  Recovery  from  the  single 
attack  is  the  rule,  while  the  likelihood  of  subsequent  attacks  is 
quite  certain.  The  prognosis  for  this  disease  is  therefore  bad 
as  to  ultimate  recovery,  although  good  for  the  separate  attacks. 


122  OUTLINES    OF    PSYCHIATRY. 

Sudden  onset  is,  on  the  whole,  rather  indicative  of  as  sudden 
recovery  and  future  attacks  may  be  presumed  to  follow,  in 
general,  the  course  of  the  past  ones.  As  the  years  go  by  the 
attacks  are  apt  to  recur  with  greater  frequency,  the  lucid  inter- 
val becoming  shorter  and  shorter,  though  even  after  a  great 
number  there  may  be  no  evidences  of  mental  deterioration 
unless,  perchance,  the  reduction  of  senescence  has  supervened 
meantime. 

Differential  Diagnosis. — The  manic  stage  may  be  confused 
with  the  excitement  of  dementia  precox.  The  presence  of 
signs  of  deterioration  in  this  latter  disease,  however,  will 
usually  make  the  diagnosis,  though  there  are  cases  that  are 
extremely  difficult  to  differentiate  and  considerable  time  must 
be  allowed  to  elapse  before  a  diagnosis  can  be  made. 

The  depressive  stage  is  more  apt  to  be  confounded  with  the 
melancholia  of  the  involution  period :  particularly  is  this  true 
of  the  mixed  state  of  agitated  depression. 

The  excited  and  stuporous  states  of  catatonia  may  be  con- 
founded. The  excitement  of  catatonia  does  not  show  typical 
flight — the  degree  of  incoherence  is  often  out  of  all  proportion 
to  the  grade  of  excitement.  The  stupor  of  catatonia  is  often 
associated  with  negativism  and  muscular  tension,  while  the  face 
is  either  expressionless  or  perhaps  grimacing.  In  depressive 
stupor  the  facial  expression  often  shows  the  great  mental  suf- 
fering of  profound  depression. 

The  great  general  principle  of  diagnosis  in  this  disease, 
aside  from  the  presence  of  the  classical  symptoms,  is  the  occur- 
rence of  repeated  attacks.  A  history  of  previous  attacks,  per- 
haps, too  mild  to  be  considered  as  such  by  the  family,  will 
almost  always  be  brought  out  by  careful  questioning.  Next  in 
importance  to  the  history  of  repeated  attacks  is  the  history  of 
attacks  of  both  manic  and  depressive  character,  often  showing 
at  their  onset  or  termination  a  short  period  of  a  mixed  state. 

It  must  not  be  forgotten,  however,  that  all  acute  psychoses 
tend  to  recur.  The  individual  once  having  suffered  from 
mental  disease  has  thereby  a  diminished  resistance  which  often 
shows  itself  in  future  attacks. 


I 


MANIC-DEPRESSIVE   INSANITY.  1 23 

Pathology. — There  are  no  characteristic  pathological  find- 
ings in  this  disease.  Patients  dying  during  an  attack  inva- 
riably succumb  to  some  intercurrent  affection,  so  that  any 
changes  primarily  produced  by  the  disease  would  be  greatly 
if  not  altogether  obscured. 

Treatment. — Many  of  the  cases  of  hypomania  require 
sequestration  because  of  their  tendency  to  commit  alcohohc 
and  sexual  excesses  and  to  make  foolish  financial  ventures. 
Further  than  this,  with  perhaps  the  occasional  exhibition  of  a 
hypnotic,  no  treatment  is  indicated. 

The  more  excited  cases  have  to  be  giiarded  particularly 
against  exhaustion.  To  this  end  great  care  should  be  taken 
to  see  that  sufficient  food  is  taken  and  prompt  recourse  had  to 
artificial  feeding  if  necessary.  For  the  insomnia  hot  milk  at 
bedtime,  hydrotherapy  (hot  pack  or  bath)  and  hypnotics 
should  be  tried  in  the  order  named.  The  coal  tar  products  are 
the  best — sulfonal,  trional,  chloralmid — while  choral  and  bro- 
mides, unless  indicated  for  some  special  reason,  should  be 
avoided.  For  the  motor  restlessness  watch  the  patient  and 
keep  him  from  injuring  himself.  Resort  may  be  had  to  the 
wet  pack  or  the  continuous  bath.  If  these  means  fail  hyoscy- 
amine  may  be  used  hypodermically. 

Three  to  five  minims  of  the  centesimal  solution  of  the  amor- 
phous sulphate  of  hyoscyamine  with  an  equal  quantity  of 
Magendie's  solution  usually  works  nicely.  The  patient  should 
always  be  kept  under  close  observation  after  such  an  injection 
and  as  the  effects  are  quite  disagreeable  and  often  continue 
during  the  next  day  it  should  not  be  repeated  unless  absolutely 
necessary.  The  judicious  use  of  hydrotherapy,  however,  will 
usually  make  it  unnecessary  to  resort  to  restraint  either  me- 
chanical or  chemical.  For  the  exhaustion,  hypodermoclysis  is 
often  valuable. 

In  the  depressed  cases  care  should  be  exercised  to  see  that 
sufficient  food  is  taken,  the  emunctories  watched,  and  the 
patient  kept  under  continuous  observation  if  there  is  any  sus- 
picion of  a  suicidal  tendency. 


CHAPTER   X. 

PARESIS. 

General  Characteristics. — General  paresis  is  an  organic 
disease  of  the  brain  of  an  inflammatory  and  degenerative 
nature,  involving  in  the  main  the  leptomeninges  and  the  cortex 
and  manifesting  itself  by  certain  physical  symptoms  and  a  pro- 
gressive mental  deterioration  upon  which  may  be  engrafted 
various  other  symptoms  of  mental  disturbance. 

Etiology. — The  etiology  of  paresis  has  long  been  a  matter 
of  contention  but  the  opinion  that  in  some  way  syphilis  is  a 
necessary  pre-condition  to  the  development  of  the  disease  is 
being  more  and  more  generally  accepted.  Perhaps  the  best 
way  to  state  the  problem  would  be  to  give  in  brief  the  separate 
arguments  that  make  for  and  against  a  syphilitic  etiology. 

Paresis  is  unknown  in  regions  where  syphilis  is  unknown. 

Under  circumstances  in  which  syphilis  is  rare  paresis  is 
likewise  rare. 

A  history  of  syphilis  is  found  much  more  frequently  in 
paresis  than  in  the  other  psychoses. 

In  juvenile  paresis  syphilis  is  always  found  in  the  parents. 

Inoculation  of  paretics  with  syphilitic  virus  fails  to  produce 
syphilis.     Conjugal  general  paresis  occurs. 

The  presence  of  a  syphilitic  anti-body  in  the  cerebro- 
spinal fluid. 

The  absence  of  signs  of  recent  syphilis  in  paretics  admitted 
to  hospitals,  though  the  irregular  life  so  many  of  these  cases 
lead  in  the  early  stages  of  their  disease  must  certainly  expose 
them. 

A  number  of  arguments  against  the  hypothesis  that  syphilis 
is  necessary  for  the  development  of  paresis  must  not  be  lost 
sight  of.     For  example: 

124 


PARESIS.  125 

All  paretics  do  not  present  a  history  of  syphilis.  Neither 
do  all  syphilitics.  Twenty  per  cent,  of  known  syphilitics  with 
well-marked  tertiary  lesions  will  not  present  a  history  of  infec- 
tion. It  must  not  be  forgotten,  too,  that  the  fact  of  syphilitic 
infection  is  not  generally  confided  to  friends  and  relatives, 
while  at  the  time  of  admission  to  the  hospital  the  patient  may 
be  in  such  a  mental  state  as  to  preclude  the  possibility  of 
getting  a  history  from  him. 

Only  a  small  percentage  of  syphilitics  develop  paresis: 
syphilis  is  the  much  more  common  disease.  The  percentage 
of  paresis,  however,  is  increasing  markedly — partly  probably 
because  it  is  being  much  more  frequently  recognized. 

Paresis  is  rare  in  certain  countries  where  syphilis  is  com- 
mon— Egypt  and  a  few  years  ago  at  least  in  Japan.  This 
would  indicate,  however,  that  other  factors  were  required  to 
reduce  cerebral  resistance  and  thus  make  it  the  locus  minoris 
resistenticu,  on  which  the  poison  might  produce  its  effect. 

Anti-syphilitic  treatment  does  not  ameliorate  the  symptoms 
in  paresis.  This  is  probably  due  to  the  fact  that  the  lesions 
are  not  directly  syphilitic,  but  that  in  all  probability  some  inter- 
mediate process  occurs — thus  syphilis  is  a  necessary  antecedent 
to  this  train  of  events  only. 

General  Considerations. — Protean  as  are  the  manifestations 
of  this  disease,  it  is  not  strange  that  it  should  often  go  unrec- 
ognized during  its  early  stages,  yet  there  is  probably  no  disease 
in  which  a  failure  to  make  a  correct  diagnosis  is  fraught  with 
such  manifest  dangers,  not  only  to  the  patient  but  to  his  family, 
his  friends,  or  in  fact  to  any  one  who,  not  recognizing  his  con- 
dition, may  be  induced,  for  instance,  to  enter  into  business 
relations  with  him.  It  is  during  this  early  period  that  those 
unfortunate  occurrences  are  so  frequent  which  might  have 
been  prevented  if  the  true  condition  of  the  patient  had  been 
recognized. 

Manifesting  itself  in  its  incipiency  by  symptoms  of  defective 
intelligence,  lack  of  judgment,  memory  defects,  and  moral 
obtuseness,  we  frequently  see  the  most  pitiful  of  pictures — a 


126  OUTLINES    OF    PSYCHIATRY. 

previously  respected  citizen,  father  of  a  family,  occupying  an 
enviable  social  position,  become  at  the  height  of  his  career 
an  ardent  worshiper  at  the  shrines  of  Venus  and  Bacchus. 
Friends  and  relatives  see  nothing  in  these  manifestations  but 
the  outcropping  of  original  sin  and  are  distracted  by  their 
inability  to  stay  the  career  of  drunkenness  and  vice  upon  which 
their  erstwhile  respected  relative  has  entered.  How  many 
heartaches,  how  many  pangs  of  anguish,  how  many  blushes  of 
shame  could  be  spared  the  wife  and  children  of  such  a  man  if 
the  family  physician  did  but  recognize  in  these  occurrences  the 
symptoms  of  the  onset  of  a  mental  disease  and  advise  them 
what  course  to  pursue. 

An  acute  attack  of  maniacal  excitement,  the  delirium  of  an 
acute  toxic  psychosis,  are  early  recognized  and  even  the  slowly 
developing  depression  of  the  melancholiac,  or  the  gradual 
change  of  character  of  the  paranoiac,  is  usually  appreciated 
befor.e  any  serious  harm  can  come.  But  here  we  have  a  dis- 
ease, afflicting  one  when  at  the  very  zenith  of  his  physical  and 
mental  powers,  insidious  in  its  onset  yet  capable  of  so  changing 
the  character  in  a  few  weeks  that  the  previously  honest,  up- 
right, moral,  truth-loving,  sober  citizen  becomes  the  votary  of 
every  form  of  vice,  sinks  to  the  depths  of  drunkenness  and 
debauchery,  and  may  even  stain  his  hands  in  blood.  But  this 
is  not  the  worst;  all  these  things  would  ultimately  find  their 
explanation  when  the  disease  that  was  responsible  for  them 
came  finally  to  be  recognized  and  in  the  light  of  its  diagnosis 
they  would  be  excused.  But  it  so  happens  that  such  a  man  as 
I  have  pictured  is  generally  the  guardian  of  the  family  ex- 
chequer. When  this  is  the  case  it  almost  invariably  happens 
that  he  wastes  considerable  amounts  of  money  in  his  debauch- 
ery, becomes  involved  in  unfortunate  and  ill-advised  specula- 
tions, often  at  the  solicitation  of  "  sharpers "  who  only  too 
well  appreciate  his  poor  judgment  and  gullibility — and  finally, 
when  he  has  succeeded  in  hopelessly  entangling  his  business 
affairs  and  plunging  himself  into  debt,  he  is  committed  to  an 
institution  and  his  family  only  then  come  to  a  realization  that 


PARESIS.  1 27 

they  are  penniless.  The  pity  of  it  all  is  that  it  might  have 
been  prevented. 

Before  taking  up  the  description  of  this  disease,  it  is  desir- 
able to  correct  two  pretty  generally  diffused  misapprehensions 
regarding  it.  First,  the  diagnosis  of  paresis  does  not  rest 
solely  upon  the  mental  symptoms.  Paresis  is  a  gross  organic 
disease  of  the  brain  and  its  diagnosis  must  rest  largely  upon 
an  appreciation  of  the  physical  signs  which  these  changes  bring 
about,  particularly  in  the  field  of  motor  disturbance.  Second, 
grandiose  delusions  of  great  wealth,  power  and  strength  are 
in  no  wise  a  necessary  part  of  the  disease,  and  while  the  so- 
called  classical  type  of  paresis  does  present  such  delusions,  still 
there  are  reasons  for  believing  that  this  type  is  becoming  less 
frequent. 

General  paresis  is  divided  into  three  periods.  First,  the 
prodromal  period ;  second,  the  period  of  the  fully  developed 
disease,  and  third,  the  terminal  period. 

First  Period. 

Physical  Symptoms. — Of  these  by  far  the  most  important 
are  the  oculo-motor  and  tendon  reflex  disturbances.  Of  the 
oculo-motor  phenomena  the  pupillary  abnormalities  are  most 
important.  The  loss  of  the  light  reflex  with  retention  of  the 
reaction  to  accommodation,  the  Argyll-Robertson  pupil,  is  one 
of  the  most  valuable  diagnostic  signs  of  beginning  paresis,  in 
the  absence  of  tabes,  as  it  frequently  occurs  very  early.  This 
symptom  is  present  in  45  per  cent,  of  cases.  A  sluggish  reac- 
tion to  light,  probably  the  beginning  stage  of  the  Argyll- 
Robertson  pupil,  is  found  in  28.3  per  cent.,  while  a  normal 
light  reflex  is  present  in  26.3  per  cent.  It  is  generally  con- 
ceded, however,  that  the  Argyll-Robertson  pupil  is  much  more 
common  in  the  tabetic  type  of  paresis — 84  per  cent.  (Bumke). 

In  this  connection  the  observations  of  Marandon  de  Montyel, 
published  in  June,  1905,  are  interesting. 

This  author  has  made  observations  on  the  light  reflex  upon 
140  paretics  from  the  beginning  of  the  disease  until  death. 


128  OUTLINES    OF    PSYCHIATRY. 

Fifty  of  the  patients  died  in  the  first  stage,  36  in  the  second, 
and  54  in  the  third.  Of  the  54  who  hved  through  the  entire 
evolution  of  the  disease  every  one  showed  some  abnormality 
at  one  time  or  another.  Of  the  140  patients,  the  reflex  v/as 
always  normal  in  24  per  cent.,  always  abnormal  in  17  per  cent., 
and  alternated  in  58  per  cent.  Taken  by  stages,  in  the  first 
stage,  42  per  cent,  were  always  normal ;  the  second  stage,  29  per 
cent.,  and  in  the  third,  3  per  cent.  Those  always  abnormal :  first 
stage,  24  per  cent.";  second,  34  per  cent.,  and  third,  85  per  cent. 
Those  which  alternated :  first  stage,  32  per  cent. ;  second,  35 
per  cent.,  and  third,  11  per  cent.  In  the  first  stage  6  per  cent, 
were  exaggerated  in  both  eyes;  10  per  cent,  showed  diminution 
and  abolition  of  the  reflex  in  one  eye. 

The  author  claims  that  this  is  the  first  complete  series  of 
cases  and  that  the  conclusions  are  much  more  reliable  than 
those  based  upon  a  much  larger  number  of  isolated  observa- 
tions taken  at  random  in  the  disease. 

In  examining  for  these  conditions  care  should  be  taken  that 
movements  of  accommodation  are  not  mistaken  for  reactions 
to  light  by  having  the  patient  fix  the  gaze  upon  some  object, 
the  pupils  should  be  equally  illuminated,  and  the  light  should 
not  be  too  bright,  as  under  these  circumstances  a  sluggish  reac- 
tion might  be  masked. 

Earlier  still  than  loss  of  the  direct  light  reflex,  Berkley 
believes,  can  often  be  found  loss  of  the  consensual  light  reflex. 
The  consensual  reflex  consists  in  the  dilatation  and  contraction 
of  the  pupil  of  one  eye  when  the  other  is  shaded  or  exposed  to 
direct  light.  It  is  quite  possible,  I  believe,  that  the  loss  of 
this  reflex  is  an  early  stage  in  the  development  of  the  Argyll- 
Robertson  pupil  and  should  always  be  tested  for.  This  con- 
dition is  usually  found  when  a  sluggish  light  reflex  is  pres- 
ent. Lewis  claims  that  a  still  earlier  symptom  than  any  of 
these  is  the  loss  of  the  sympathetic  reflex  (the  dilatation  of 
the  pupil  on  stimulating  the  skin  of  the  neck).  Sixty-three 
and  six  tenths  per  cent,  of  his  cases  showed  this  symptom, 
several  of  them  with  light  and  consensual  reflexes. 


PARESIS.  1 29 

Of  the  tendon  reflexes  the  only  one  that  need  be  considered 
is  the  knee-jerk.  This  may  be  normal,  exaggerated,  dimin- 
ished or  lost  on  one  or  both  sides.  The  exaggerated  reflex  is 
most  common,  but  I  agree  with  Sommer  in  his  statement  that 
although  this  is  so  the  absence  of  the  knee-jerk  is  of  much 
greater  diagnostic  importance,  as  there  are  many  more  causes 
for  its  exaggeration  other  than  paresis  than  there  are  for  its 
abolition.  This  sign,  also,  of  course,  depends  for  its  impor- 
tance upon  the  elimination  of  other  possible  etiological  factors, 
especially  tabes. 

Mental  Symptoms. — The  mental  symptoms  of  the  prodromal 
period  are  often  not  appreciated  at  the  time  of  their  occur- 
rence but  only  after  the  disease  has  been  recognized  in  its  fully 
developed  state  and  then  in  looking  back  over  the  past  few- 
months  various  occurrences  which  were  then  not  appreciated 
at  their  true  value  are  seen  in  their  real  relation  to  the  develop- 
ment of  the  disease. 

In  general,  these  mental  symptoms  are  symptoms  of  a 
gradual  change  of  character  and  of  progressively  failing 
mental  and  physical  powers.  There  is  a  beginning  failure  on 
the  part  of  the  patient  to  continuously  apply  himself  to  his 
work  and  mental  application  of  any  sort  soon  brings  on  fatigue ; 
memory  is  not  quite  so  good  and  business  engagements  and 
the  details  of  business  are  forgotten,  the  morale  of  the  patient 
is  quite  apt  to  undergo  alteration,  and  he  may  go  to  excess  in 
drinking  and  associate  with  lewd  women  oftentimes  openly, 
without  shame,  which  is  of  course  of  most  significance  if  con- 
trary to  his  previous  habits  and  ideals.  In  addition  to  these 
symptoms  he  shows  poor  judgment  in  his  business  relations 
and  may  not  only  risk  large  sums  of  money  on  hair-brained 
schemes,  but  may  enter  into  all  sorts  of  financial  relations  with 
persons  and  preserve  no  records  to  show  what  they  were. 

The  appearance  of  the  patient  may  also  indicate  the  begin- 
ning of  mental  reduction :  he  is  less  careful  about  his  personal 
appearance,  wears  soiled  linen,  has  forgotten  to  button  his  vest, 
or  to  put  on  a  necktie ;  his  clothes  are  shabby  and  soiled,  and  in 


130  OUTLINES    OF    PSYCHIATRY. 

general  the  degradation  toward  which  his  condition  is  tending 
has  begun  to  show  itself. 

The  mental  symptoms,  as  already  indicated,  are  symptoms  of 
dementia,  gradual,  progressive,  and  more  or  less  uniform  failure 
of  the  mental  powders  upon  which,  it  is  true,  may  be  engrafted 
the  picture  of  almost  any  psychosis,  but  which  inevitably  and 
of  necessity  modify  that  picture  in  a  way  more  or  less  charac- 
teristic of  the  underlying  defect.  This  dementia  manifests 
itself  by  failure  of  memory,  defective  judgment,  inability  to 
apply  the  mind  consecutively  for  any  length  of  time,  and 
failure  of  the  moral  sense.  The  picture,  from  a  mental  view- 
point, is  then  one  of  a  gradually  deepening  dementia,  corre- 
lated with  organic  changes  in  the  cerebral  cortex,  a  true  organic 
dementia.  If  upon  this  basis  of  organic  dementia  there  be 
erected  mayhap  symptoms  of  excitement  or  depression,  delu- 
sions of  a  hypochondriacal  or  grandiose  nature,  multiform  hal- 
lucinations and  illusions,  a  true  delirium,  these  symptoms  may 
properly  be  considered  as  unessential,  accidental  accompani- 
ments. Thus  a  distinction  is  made  between  paralytic  dementia, 
the  direct  result  of  the  destruction  of  brain  tissue  and  the  fun- 
damental symptom,  on  the  mental  side  of  the  disease,  and  para- 
lytic insanity,  which  consists  of  the  various  other  symptoms  of 
mental  disturbance  which  may  be  engrafted  on  the  demented 
background. 

Developing  as  they  do,  however,  upon  a  groundwork  of 
dementia,  we  w^ould  expect  them  to  manifest  themselves  differ- 
ently than  would  be  the  case  if  their  foundation  had  been 
originally  an  unimpaired  mind.  This  we  find  preeminently  to 
be  the  case.  The  grandiose  paretic  is  not  content  with  possess- 
ing a  few  paltry  thousands  but  reckons  his  fortune  by  quintil- 
lions;  he  has  solid  gold  carriages,  harnesses  set  in  precious 
stones  and  offers  me  each  morning  a  fleet  of  ships  to  go  around 
the  world  w^ith,  a  million  dollars  and  a  thousand  wives.  The 
depressed  paretic  has  caused  the  death  of  untold  myriads  of 
human  beings,  the  hypochondriacal  has  no  stomach,  no  bowels, 
no  brains,  etc.     The  delusions  are  marked  by  an  absurdity 


PARESIS.  131 

which  can  only  result  from  the  defective  judgment  and  im- 
paired intelligence  of  dementia. 

These  advanced  conditions  of  delusional  states  are  not 
usually  found  in  this  period  of  the  disease  but  belong  typically 
to  the  next,  the  period  of  full  development.  They  are  quoted 
here  merely  to  illustrate  fully  what  is  meant  by  the  statement 
that  the  dementia  of  paresis  is  the  underlying  and  essential 
symptom.  The  demented  type,  without  marked  delusions  or 
sensory  falsifications,  is  the  truly  typical  variety  of  the  disease 
and  the  dementia  the  basal  element  of  all  forms. 

This  dementia  may,  however,  not  be  apparent,  it  may  be 
necessary  to  seek  for  its  manifestations.  In  the  very  early 
stages  the  outward  symptoms  may  be  those  of  irritability  and 
an  untoward  restlessness  which  may  exhibit  itself  in  many 
ways,  as,  for  instance,  useless  business  activity,  fits  of  violent 
rage  over  trivial  annoyances,  and  slight  lapses  of  memory.  If 
the  reasons  for  all  these  things  be  inquired  into,  however,  they 
will  be  found  inadequate,  often  puerile. 

We  find  often  in  this  stage  of  the  disease  the  beginnings  of 
those  speech  defects  which  later  are  to  become  so  characteristic. 
At  this  time  there  may  be  only  a  suspicion  of  the  true  paretic 
speech  in  the  slight  hesitation  and  occasional  almost  unnotice- 
able  defect  in  a  single  word.  Such  patients  often  say  test 
words,  such  as  hippopotamus,  communicability,  circumstan- 
tiality, perambulator,  quite  correctly.  It  would  seem  that  the 
defect  is  as  yet  so  slight  that  the  mere  effort  as  the  result  of 
conscious  attention  is  sufficient  to  overcome  it.  In  such  cases 
the  test  words  should  be  combined  into  sentences  to  catch  the 
patient  unawares,  as  it  were.  I  had  a  patient  who  said  test 
words  and  phrases  perfectly,  yet  there  was  a  noticeable  defect 
in  an  occasional  word  in  her  ordinary  conversation.  If  she 
were  asked,  however,  to  repeat  this  word  it  was  done  promptly 
and  correctly.  If  the  speech  defect  is  slightly  more  marked 
we  may  notice  a  slight  tremor  about  the  muscles  of  the  mouth 
which  is  brought  out  by  a  difficult  word  or  by  emotional  excite- 
ment.    We  should  be  careful  in  interpreting  this  tremor,  how- 


132  OUTLINES    OF    PSYCHIATRY. 

ever,  as  we  find  it  present  in  many  conditions  other  than 
paresis. 

Second  Period. 

Physical  Symptoms. — The  symptoms  already  described  be- 
come more  marked.  The  tremor  especially  is  more  in  evidence 
and  is  of  the  fibrillary  variety ;  the  muscular  weakness  is  notice- 
able and  is  in  marked  contrast  to  the  well-nourished  appear- 
ance of  the  patient,  who  quite  characteristically  takes  on  flesh 
in  this  stage;  the  Romberg  symptom  becomes  much  more 
marked,  so  that  the  patient  may  fall  when  the  eyes  are  shut; 
the  walk  is  more  ataxic — especially  in  those  cases  that  have 
begun  with  tabetic  symptoms — the  tabetic  variety. 

Characteristic  of  paresis,  and  occasionally  but  not  frequently 
occurring  early  in  its  course,  are  the  so-called  paretic  seizures 
which  arbitrarily  may  be  said  to  mark  the  beginning  of  the 
second  stage.  These  may  vary  in  severity  and  character  from 
light  syncopal  attacks  with  pallor  and  temporary  prostration 
to  severe  apoplectiform  and  epileptiform  crises.  The  epilepti- 
form attacks  may  be  of  the  petit  mal  or  grand  mal  type  and 
v/ithout  the  history  may  be  indistinguishable  from  true  epilepsy. 

These  epileptiform  seizures  may  be  severe  or  slight  and  may 
involve  any  portion  of  the  musculature  and  be  accompanied  by 
loss  of  consciousness  or  not.  Occasionally  a  seizure  is  the  first 
symptom  to  attract  attention,  and  if  the  patient  is  alcoholic,  it 
may  under  such  circumstances  be  extremely  difficult  to  make  a 
diagnosis  from  alcoholic  epilepsy.  In  general,  the  seizures  last 
longer  than  the  epileptic  convulsion,  and  occurring  in  a  person 
thirty  to  forty  years  of  age  without  previous  history  of  epi- 
lepsy or  alcoholism,  should  at  once  suggest  paresis.  They  are 
less  apt  to  be  associated  with  loss  of  consciousness.  Occasion- 
ally these  seizures  last  for  days,  the  muscular  twitching  spread- 
ing from  one  part  of  the  body  to  another,  with  clouding  of 
consciousness  but  not  complete  unconsciousness  all  of  the  time. 
There  may  also  be  conjugate  deviation  of  the  eyes  and  in  many 
cases  a  marked  rise  of  temperature.     Under  such  circumstances 


PARESIS.  133 

pneumonia  is  particularly  to  be  feared  as  a  fatal  intercurrent 
disease. 

The  apoplectiform  seizures  resemble  in  every  way  true 
apoplexy  but  the  resulting  paralysis  is  less  apt  to  be  permanent ; 
in  fact,  it  may  entirely  disappear  in  a  most  remarkable  fashion 
in  two  or  three  days.  It  must  not  be  forgotten  that  the  paretic 
may,  of  course,  have  a  frank  apoplectic  attack  with  resulting 
permanent  paralysis.  Transitory  muscular  paralyses,  not  in- 
frequently of  the  extrinsic  eye  muscles,  may,  however,  occur 
apart  from  these  seizures.  They  are  of  short  duration  and 
clear  up  rapidly. 

After  a  seizure  it  is  usual  to  find  that  the  patient  is  some- 
what more  demented.  This  is  a  distinguishing  feature  from 
epilepsy. 

The  causes  of  these  seizures  can  not  be  satisfactorily  ex- 
plained, but  they  are  perhaps  due  to  local  conditions  in  the 
brain  of  both  toxicity  and  edema.  They  may  be  explained  as 
a  result  of  the  extensive  destructive  process  going  on  and  the 
clogging  of  the  lymph  channels,  so  that  the  waste  products 
cannot  be  removed  readily. 

Mental  Symptoms. — The  mental  symptoms  of  this  period 
are  merely  more  exaggerated  expressions  of  those  already  de- 
scribed. The  symptoms  of  mental  reduction — dementia — ^be- 
come more  and  more  prominent.  Memory  fails  utterly,  so  that 
the  patient  may  not  recall  the  location  of  his  room  that  he  has 
lived  in  for  weeks;  spatial,  temporal  and  personal  disorienta- 
tion appear;  a  true  occupation  delirium  may  develop,  the  pa- 
tient being  often  found  carrying  on  his  accustomed  business 
operations  oblivious  of  his  surroundings;  the  simplest  mental 
operations,  such  as  adding  a  column  of  figures,  have  become 
impossible;  the  emotional  deterioration  is  prominent,  the  pa- 
tient pays  no  attention  to  his  family  and  may  not  be  affected 
even  by  the  death  of  one  of  them.  The  speech  disturbance 
which  has  been  in  evidence  usually  for  some  time  becomes 
much  more  prominent.  Syllables  are  reduplicated,  words  are 
left  out  or  stumbled  over,  the  voice  is  harsh  and  lacking  in 


134  OUTLINES    OF    PSYCHIATRY. 

expression.  The  writing  presents  similar  defects  and  although 
sometimes  the  first  few  words  are  fairly  done  soon  becomes 
almost  absolutely  illegible,  a  mass  of  scrolls,  blots,  erasures, 
or  the  patient  may  fail  absolutely  after  several  efforts  to 
write  at  all. 

In  this  fully  developed  stage  the  disease  occurs  in  four  types, 
viz.,  the  demented,  excited,  agitated  and  depressed. 

The  demented  type,  as  has  been  explained,  constitutes  the 
typical  variety  of  the  disease  and  is  the  type  which  has  been 
thus  far  described. 

The  excited  or  expansive  type  is  marked  by  more  active 
symptoms  and  typically  by  grandiose  delusions.  This  consti- 
tutes the  so-called  classical  paralysis.  These  ideas  of  grandeur 
are  marked,  as  already  explained,  by  their  absurd  character, 
the  patients  believing  themselves  to  have  great  strength,  they 
can  lift  enormous  weights,  have  fabulous  wealth,  so  much 
money  in  fact  that  ordinary  words  are  insufficient  to  express 
the  amount  and  words  have  to  be  invented  for  that  purpose, 
possess  thousands  of  carriages  with  trimmings  of  gold  and 
precious  stones,  fleets  of  vessels  to  take  friends  on  tours  about 
the  world,  write  checks  for  millions  and  distribute  them  indis- 
criminately. One  patient  was  importing  carloads  of  blood- 
hounds, another's  eyes  were  brighter  than  any  light  invented 
by  man  and  even  when  shut  served  to  illuminate  the  room 
about  him.  With  these  delusional  symptoms  there  goes  a 
great  deal  of  motor  unrest,  the  patient  constantly  busies  him- 
self drawing  up  schemes,  writing  checks,  talking,  etc.,  and 
suffers  from  insomnia. 

The  agitated  type,  sometimes  called  when  extreme  galloping 
/)arr.9/^,  is  a  more  aggravated  form  of  the  excited  type.  In  this 
condition  the  motor  restlessness  and  insomnia  is  extreme,  there 
supervenes  marked  emaciation,  the  delusions,  while  of  the  ex- 
pansive type,  are  rapidly  changeable  and  there  is  marked  flight 
of  ideas,  with  considerable  clouding  of  consciousness.  Some 
temperature  usually  coexists  and  the  case  runs  a  rapidly  fatal 
course  from  exhaustion.     All  grades  of  excitement  may,  of 


PARESIS.  135 

course,  occur  between  the  classical  type  on  the  one  hand  and 
the  extreme  form  of  the  agitated  type — galloping  paresis — on 
the  other. 

The  depressed  type  is  often  at  first  mistaken  for  melancholia, 
and  this  mistake  is  liable  to  be  made  unless  the  physical  symp- 
toms are  borne  in  mind.  The  depression  may  take  the  form  of 
depressive  melancholia  with  retardation  or  of  affective  melan^ 
cholia  with  anxiety  and  apprehension.  Delusions  are  frequent 
and  often  take  the  form  of  hypochondriacal  ideas — the  bowels 
are  stopped  up,  the  blood  does  not  circulate,  and  the  like,  or 
ideas  of  negation,  the  patient  denying  that  he  has  a  stomach, 
brain,  soul,  head,  or  even  claiming  that  he  is  dead. 

Sometimes  states  of  depression  and  excitement  alternate,  so 
producing  a  circular  paralytic  insanity. 

Delusions  of  a  persecutory  character  may  give  a  paranoid 
type  to  the  symptom-complex,  while  in  some  cases  the  Korsa- 
kozv  syndrome  is  present. 

Third  Period. 

As  the  second  period  may  be  arbitrarily  said  to  be  ushered 
in  by  the  paretic  seizure,  so  the  third  period  may  be  arbitrarily 
said  to  date  from  the  time  when  the  patient  begins  to  soil 
himself. 

Physical  Symptoms. — All  the  physical  symptoms  become 
more  marked  at  this  stage.  The  tremor  is  constant,  the  ataxia 
has  increased  to  such  an  extent  that  locomotion  becomes  dan- 
gerous or  quite  impossible  and  because  of  the  friable  condition 
of  the  bones  falls  are  liable  to  produce  fractures,  muscular 
weakness  is  marked  and  emaciation  becomes  extreme.  In  this 
enfeebled  condition  the  patient  becomes  bedridden,  contrac- 
tures quite  often  develop  in  the  extremities  and  control  of  the 
sphincters  is  lost.  Often  a  contracture  of  the  neck  muscles 
develops,  so  that  the  head  is  kept  raised  from  the  pillows  in  a 
characteristic  attitude,  and  not  infrequently  the  patient  grinds 
the  teeth  for  hours  at  a  time.  The  paretic  seizures  become 
more  frequent,  bed  sores  develop  over  all  the  bony  prominences 


1^.6 


OUTLINES    OF    PSYCHIATRY. 


unless  the  most  scrupulous  care  is  taken  to  prevent  them,  ex- 
haustion occurs  and  the  patient  dies  in  a  seizure,  from  maras- 
mus, or  some  intercurrent  affection. 

Mental  Symptoms. — In  the  mental  sphere,  as  in  the  physical, 
there  continues  to  be  a  progressive  degradation.  The  dementia 
becomes  profound,  so  that  the  patient  may  not  even  know  his 
own  name — he  ceases  absolutely  to  lead  a  mental  life  and  leads 
only  a  vegetative  existence.  Often  in  the  mass  of  stammering, 
stumbling,  incoherent  sounds  a  word  here  and  there  will  indi- 
cate the  remains  of  former  delusions.  It  is,  however,  not  un- 
common for  the  symptoms  of  paralytic  insanity  to  disappear  in 
this  stage  and  for  the  case  to  terminate  in  uncomplicated  de- 
mentia. Finally,  if  no  intercurrent  malady  supervenes,  the 
patient  sinks  into  coma  and  dies. 

Pathology. — In  opening  the  calvarium  the  dura  is  found 
abnormally  adherent  to  the  skull  cap  and  internally  may  present 
areas  of  hemorrhagic  pachymeningitis.  The  surface  of  the 
brain  shows  areas  of  congestion  more  frequently  in  the  frontal, 
parietal  and  temporal  regions  than  in  the  occipital.  The  lepto- 
meninges  are  thickened,  opaque,  and  along  the  lines  of  the 
great  vessels  contain  a  milky,  opalescent  fluid.  In  attempting 
to  remove  them  they  are  found  abnormally  adherent,  so  that 
portions  of  the  cortex  are  torn  off  with  them — decortication — 
giving  a  worm-eaten  appearance  to  the  denuded  surface.  This 
appearance  is  very  characteristic  and  is  almost  always  present, 
except  perhaps  early  or  in  the  very  late  stages  when  a  sub- 
pial  collection  of  serum  has  raised  the  membranes  from  the 
brain  so  far  they  may  be  readily  removed. 

Microscopically  there  is  found  a  round-celled  infiltration  of 
the  adventitia  of  the  vessel  walls,  the  lymph  sheath  of  the  pia, 
and  the  brain  substance,  dilation  of  the  lymph  channels  and 
filling  and  even  blocking  of  these  channels  with  round  cells, 
leukocytes  and  granular  detritus,  thus  interfering  with  lymph 
circulation  and  impairing  brain  nutrition.  There  are  also 
found  degenerative  changes  in  the  vessel  walls  and  an  increase 
of  neuroglia,  the  podasteroid  cells — adjuncts  of  the  lymph- 


PARESIS.  137 

vascular  system — becoming  swollen  and  granular  in  their 
effort  to  remove  the  waste  material. 

The  nerve  cells  undergo  a  progressive  degeneration,  the 
Nissl  granules  break  up  into  a  mass  of  detritus  and  finally  dis- 
appear. The  affected  areas  also  show  degeneration  of  nerve 
fibers. 

Associated  with  the  breaking  down  of  the  nerve  elements  is 
an  increase  in  the  neuroglia,  particularly  noticeable  in  the  in- 
crease of  the  sub-pial  felting. 

Numerous  cells  known  as  plasma  cells  are  quite  regularly 
found.  Their  origin  is  not  satisfactorily  explained.  Whether 
they  are  transformed  leukocytes  or  derived  from  the  connective 
tissue  is  a  mooted  question.  Stabchenzellen,  elongated,  nu- 
cleated cells  are  also  quite  characteristic. 

Although  the  cortex  is  most  prominently  affected,  other  por- 
tions of  the  brain,  together  with  the  spinal  cord,  are  usually 
involved,  while  the  general  disturbance  of  nutrition  is  shown 
in  diseased  and  degenerated  conditions  of  various  other  organs, 
particularly  the  kidneys. 

While  the  pathology  of  paresis  discloses  both  inflammatory 
and  degenerative  lesions,  it  is  still  a  mooted  point  which 
process — inflammation  or  degeneration — should  be  considered 
as  primary. 

Diagnosis. — One  of  the  recent  aids  to  the  diagnosis  of 
paresis  is  by  the  method  of  examination  of  the  spinal  fluid. 
A  well-marked  lymphocytosis  will  serve  to  differentiate  this 
disease  from  the  so-called  vesanias  or  functional  insanities  but 
not  of  course  from  other  conditions  in  which  the  meninges  are 
seriously  involved. 

The  principal  diseases  for  which  paresis  may  be  mistaken, 
especially  in  the  early  stages,  are  tabes,  acquired  neurasthenia, 
alcoholism,  brain  tumor,  cerebral  syphilis,  disseminated  sclero- 
sis, the  functional  psychoses,  epilepsy  and  arterio-sclerotic 
dementia. 

The  principles  of  its  differentiation  from  the  various  psy- 
choses have  been   already   indicated.      The  presence   of   the 


138  OUTLINES    OF    PSYCHIATRY. 

underlying  dementia  in  a  person  of  middle  age  should  make 
us  at  once  suspicious  and  if  to  this  condition  the  physical  signs 
can  be  added  a  diagnosis  can  with  certainty  be  made. 

From  tabes  dorsalis  the  differentiation  is  not  so  easy,  and  in 
fact  there  remain  a  few  cases  where  it  is  impossible,  and  we 
must  wait  for  the  development  of  further  symptoms.  This  is 
due  to  the  fact  that  in  their  early  stages  the  physical  signs  may 
be  identical  in  the  two  diseases.  When,  however,  we  observe 
a  case  in  which  the  tabetic  signs  are  somewhat  atypical  with, 
for  instance,  preservation  of  knee-jerks  or  marked  ataxia  of 
the  arms,  we  may  be  suspicious  of  paresis  and  if  with  this  con- 
dition we  find  associated  evidences  of  mental  disturbance  a 
tentative  diagnosis  is  in  order. 

In  differentiating  paresis  from  acquired  neurasthenia  the 
general  mental  attitude  of  the  patient  is  of  great  significance. 
Whereas  the  neurasthenic  is  given  to  exaggerating  his  ills,  to 
constantly  complaining  of  his  aches  and  pains,  and  keeps  close 
observation  of  every  change  of  symptoms,  the  paretic  is  usually 
indifferent  or  may  on  the  contrary  consult  a  physician  under 
protest  and  in  the  firm  belief  of  the  uselessness  of  so  doing  as 
he  feels  so  well.  This  is  not  invariable,  as  I  have  seen  paretics 
well  advanced  in  the  disease  who  were  much  concerned  over 
their  condition.  The  contrary  state  of  mind,  as  illustrated  by 
one  of  my  patients,  is  more  common.  On  her  admission  I  dis- 
covered a  well-marked  hemiplegia  which  she  actually  knew 
nothing  of  until  I  called  her  attention  to  it.  In  addition  to 
this,  there  is  in  neurasthenia  no  dementia,  no  disturbance  of 
speech  or  writing,  no  history  of  seizures,  the  tendon  reflexes 
are  equal  and  not  abolished,  the  pupils  equal,  respond  to  light 
and  accommodation  and  are  more  apt  to  be  dilated,  while  in 
paresis  they  are  frequently  unequal  and  often  very  much 
contracted. 

From  alcoholism  the  diagnosis  is  often  not  so  easy.  The 
deterioration  of  the  chronic  alcoholic  has  much  in  common  with 
the  dementia  of  paresis.  Here  again  we  must  turn  to  the 
physical  signs  and  note  carefully  the  historic  facts.     Follow- 


PARESIS.  1 39 

ing  a  long  debauch,  however,  symptoms  may  arise,  which,  in 
the  absence  of  a  history,  would  warrant  a  diagnosis  of  paresis 
— the  so-called  alcoholic  pseiido-parcsis.  These  symptoms  dis- 
appear, though,  in  a  remarkable  manner  when  the  alcohol  is 
withdrawn. 

In  toxic  conditions  generally  sluggish  reaction  of  the  pupil 
to  light  is  not  uncommon,  while  Argyll-Robertson  pupil  may 
probably  occur  for  only  a  temporary  period. 

Symptoms  occasionally  develop  in  the  course  of  brain  tumor 
which  closely  resemble  paresis.  The  diagnosis  must  be  made 
on  the  preeminently  focal  character  of  the  physical  signs  in 
the  former  disease. 

From  disseminated  sclerosis  the  differentiation  is  sometimes 
difficult.  The  combination  of  intention  tremor,  nystagmus, 
scanning  speech  and  spasticity  will,  however,  usually  leave 
little  room  for  doubt,  although  some  of  these  cases  do  ulti- 
mately develop  typical  signs  of  paresis. 

From  cerebral  or  cerebrospinal  syphilis  the  diagnosis  is  again 
quite  difficult.  If  the  lesion  is  a  gummatous  meningitis  the 
signs  are  rather  of  multiple  lesions  than  a  diffuse  process.  If, 
on  the  other  hand,  the  disease  affects  principally  the  vessels, 
with  resulting  endarteritis  obliterans,  thrombosis  and  soften- 
ing, the  symptoms  are  focal  and  convulsions  developing  after- 
ward constitute  a  true  post-apoplectic  epilepsy.  Disturbances 
of  speech  either  are  not  present,  or,  if  they  are,  do  not  partake 
of  the  nature  of  a  paretic  disorder  but  are  true  aphasia,  due 
to  focal  lesions.  Palsies,  if  present,  are  permanent  and  noc- 
turnal headaches  common.  The  age  of  onset  should  be  con- 
sidered. Under  thirty  syphilis  is  more  commonly  found  to  be 
the  cause  of  cerebral  manifestations  than  paresis.  It  must  not 
be  forgotten  that  sluggish  reaction  to  light  and  even  Argyll- 
Robertson  pupil  may  be  found  in  cerebral  syphilis. 

From  the  so-called  functional  psychoses  a  differential  diag- 
nosis may  be  difficult  in  the  early  stages,  especially  if  there  are 
marked  emotional  disorders  or  paranoid  delusions.  The  pres- 
ence of  the  physical  signs  of  paresis  associated  with  symptoms 


140  OUTLINES    OF    PSYCHIATRY. 

of  dementia  and  the  cytological  examination  of  the  cerebro- 
spinal fluid  will  usually  clear  up  the  difficulty. 

In  the  early  stages  in  those  cases  that  have  been  ushered  in 
by  a  paretic  seizure  epilepsy  may  be  suspected.  The  absence 
of  the  history  of  epilepsy  should  suggest  paresis. 

The  diffusion  of  the  destructive  lesions  in  arteriosclerotic 
dementia  is  not  infrequently  responsible  for  a  picture  closely 
resembling  paresis.  This  condition  occurs  much  later  in  life, 
usually  after  the  sixtieth  year ;  there  are  evidences  of  advanced 
vascular  disease,  and  the  characteristic  senile  disorder  of 
memory  is  present. 

Course  and  Prognosis. — The  disease  may  be  said  to  be 
absolutely  fatal,  although  an  occasional  alleged  cure  is  re- 
ported. Remission  quite  frequently  occurs,  so  that  the  patient 
may  be  well  enough  to  leave  the  hospital  and  remain  away  for 
weeks  or  even  months.  The  fact  that  remissions  occur  should 
never  be  forgotten  in  giving  a  prognosis  to  the  relatives.  The 
acute  forms  of  the  disease  are  rapidly  fatal,  the  majority  die 
in  from  eighteen  months  to  three  years,  while  in  a  certain 
few  cases  the  disease  process  is  very  slow  and  may  occupy 
many  years. 

Death  usually  occurs  from  some  intercurrent  affection,  pneu- 
monia, cystitis,  terminal  infection,  or  from  the  disease  itself, 
which  leads  to  an  extreme  degree  of  emaciation  and  exhaustion. 

Treatment. — This  disease  is  from  the  first  preeminently  a 
disease  for  institution  care.  The  patient  is  absolutely  unable 
to  care  for  himself  and  in  the  great  majority  of  instances  the 
friends  are  equally  unable  to  care  for  him.  As  soon  as  the 
diagnosis  is  made  steps  should  be  taken  looking  towards  the 
appointment  of  a  committee  of  his  person  and  property  or 
otherwise  guarding  his  business  interests,  which  upon  investi- 
gation will  show  almost  without  fail  evidences  of  poor  man- 
agement, the  result  of  early  manifestation  of  the  dementia. 

Medicinally  there  is  really  little  to  be  done  except  to  treat 
conditions  as  they  arise  in  accordance  with  general  principles. 
The  disease  is  inevitably  fatal  in  spite  of  anything  that  can  be 


PARESIS.  141 

done.  Anti-syphilitic  treatment  may  be  tried,  but  as  in  tabes, 
little  is  to  be  expected  from  it,  while  a  too  heroic  exhibition  of 
mercury  and  the  iodides  may  actually  aggravate  the  symptoms 
and  hasten  the  degradation. 

Tube  feeding  may  have  to  be  early  resorted  to  because  of 
the  development  of  dysphagia  and  the  consequent  danger  of 
choking.  The  most  scrupulous  care  should  be  taken  to  pre- 
vent the  development  of  bed-sores,  as  they  are  practically 
impossible  to  heal  and  do  much  towards  hastening  the  fatal 
termination. 


CHAPTER   XI. 
DEMENTIA   PRECOX. 

General  Characteristics. — Dementia  precox  is  a  psychosis 
essentially  of  the  period  of  puberty  and  adolescence,  charac- 
terized by  a  dementia  tending  to  progress,  though  frequently 
interrupted  by  remissions.  Upon  the  foundation  of  dementia 
are  erected  various  psychotic  symptoms,  many  of  which  show 
a  marked  tendency  to  episodic  manifestations. 

Etiology. — Dementia  precox  is  essentially  a  disease,  as 
stated,  of  the  period  of  puberty  and  adolescence.  Heredity 
plays  a  marked  role  in  its  etiology  and  the  disease  seems  often 
to  occur  repeatedly  in  the  same  families.  The  future  patient 
might  be  expected  to  be  rather  dull  in  his  early  youth  and 
show  difficulty  in  getting  on  with  his  studies.  While  this  is 
not  infrequently  the  case,  still  cases  often  occur  in  young 
persons,  not  only  of  apparently  usual  mental  power,  but  of 
brilliant,  perhaps  precociously  brilliant,  faculties.  This  has 
thrown  some  doubt  on  the  hereditary  basis  of  the  disease,  espe- 
cially as  sometimes  no  serious  taint  can  be  found  in  the  antece- 
dents. In  this  particular  form  of  mental  alienation,  I  think 
it  is,  however,  especially  important  to  search  for  other  than 
distinctly  mental  disease  in  the  ancestors  of  these  patients. 

Every  individual  born  into  the  world  has,  if  it  could  be 
determined,  a  definite  potentiality  for  development.  The  force 
of  the  impetus  which  starts  it  on  its  path  is  sufficient  to  carry 
it  a  certain  definite  distance.  The  predetermined  goal,  in  each 
case,  will  be  reached  if  no  accident  intervenes  to  prevent.  In 
the  subject  of  this  disease  the  original  impetus  has  been  weak, 
only  sufficient  to  carry  them  a  short  way  and  when  its  force 
is  spent  development  stops  and  the  retrograde  process  is  has- 
tened, or  perhaps  immediately  initiated  by  some  special  phys- 

142 


DEMENTIA    PRECOX.  143 

ical  or  mental  stress  occurring  at  the  critical  point  of  puberty 
and  adolescent  evolution.  As  the  French  have  it,  these  pa- 
tients are  "  stranded  on  the  rock  of  puberty." 

If  this  is  a  true  conception  of  the  nature  of  the  hereditary 
factor  in  these  cases  it  is  readily  seen  that  it  becomes  important 
to  search  especially  for  evidences  of  debilitating  influences  in 
early  life — masturbation,  excessive  study — or  conditions  affect- 
ing the  health  and  strength  of  parents  at  the  time  of  impreg- 
nation or  during  pregnancy — alcoholism,  tuberculosis,  extreme 
age,  neurasthenia. 

Aside  from  this  class  of  causes,  direct  heredity  is  frequently 
in  evidence,  and  we  frequently  find  families  with  several  cases 
of  dementia  precox  in  them,  just  as  we  find  similar  conditions 
in  manic-depressive  insanity. 

Of  exciting  causes  it  would  seem  that  we  frequently  find 
severe  shocks,  both  physical  and  mental,  as,  for  example,  se- 
vere hemorrhages,  infections, — often  puerperal, — fright,  and 
that  train  of  emotional  disturbances  following  seduction  and 
desertion. 

Recently  a  great  deal  has  been  said  about  a  possible  toxic 
factor  as  being  responsible  for  the  disease  and  this  toxic  factor 
has  been  supposed  to  have  its  origin  in  some  of  the  glands 
after  the  analogy  of  the  toxin  in  thyroidism — probably  some 
internal  secretion  of  the  testicle  or  ovary,  as  the  disease  is  so 
closely  associated  with  the  changes  incident  to  puberty.  Then, 
again,  the  changes  of  metabolism  in  this  disease  are  quite  pro- 
nounced and  are  thought  to  find  their  explanation  in  a  toxemia. 

General  Symptomatology.  Mental:  As  in  dealing  with 
the  mental  symptoms  of  general  paresis  and  the  senium,  so  here 
we  may  consider  that  we  have  a  disease  which  is  typically  a 
dementia  from  beginning  to  end,  and  that  upon  this  ground- 
work of  dementia  various  psychotic  symptoms  may  be  en- 
grafted. True,  in  certain  cases  the  early  symptoms  do  not 
indicate  the  dementia  at  all  well,  but  tlien  this  conception  of 
the  disease,  as  in  the  other  two  cases  mentioned,  I  think,  aids 
somewhat  in  its  comprehension.     All  of  the  various  mental 


144  OUTLINES    OF    PSYCHIATRY. 

symptoms  must  be  considered  as  having  this  demented  founda- 
tion and  as  being  modified  in  their  expression  because  of  it. 

The  general  symptoms  of  the  disease  that  are  common  to  all 
varieties  are,  as  might  be  expected,  the  symptoms  of  mental 
deterioration,  of  decreased  mental  efficiency. 

One  of  the  chief  and  most  important  of  these  symptoms  is 
the  failure  of  voluntary  attention  and  the  lack  of  interest  which 
these  patients  show  both  in  themselves  and  their  surroundings. 
They  care  little  if  at  all  about  what  goes  on  about  them,  and 
although  confined  in  an  institution,  express  themselves  as  sat- 
isfied with  their  condition  and  have  no  desire  to  leave.  They 
sit  idly  about,  giving  no  heed  to  what  goes  on  about  them,  are 
unable  to  apply  themselves  to  any  sort  of  work  or  even  read- 
ing, and  when  questioned  may  even  pay  so  little  attention  as 
not  to  understand  what  is  said  to  them,  so  that  the  question  has 
to  be  repeated. 

From  this  lack  of  attention  things  in  the  environment  are 
often  not  perceived  at  all,  but  when  they  are  perceived  they  are 
understood  quite  fully,  and  we  usually  find  these  patients  are 
well  oriented  in  all  respects,  temporal,  spacial  and  personal, 
and  show  no  evidences  of  clouding  of  consciousness. 

The  memory  is  usually  defective,  especially  for  recent  events, 
reminding  us  of  the  memory  defect  of  senescence.  This  de- 
fect, to  a  certain  extent,  is  undoubtedly  apparent  only  and 
dependent  upon  lack  of  perceptions  because  of  the  inability  to 
fix  the  attention.  An  event  which  is  not  perceived  will,  of 
course,  not  be  remembered,  and  similarly  an  event  which  is 
only  perceived  in  a  desultory  manner  and  not  fully  compre- 
hended will  not  be  recalled  at  its  true  value.  It  becomes  quite 
difficult,  therefore,  to  differentiate  the  elements  of  this  defect 
and  tell  how  much  is  due  to  a  disorder  of  memory  per  se. 
Undoubtedly  a  certain  proportion  of  it  is,  though,  and  this 
defect  is  probably,  largely  at  least,  a  defect  of  impressibility. 

Knowledge  acquired  before  the  disease  began,  however, 
especially,  therefore,  as  these  patients  are  already  quite  young, 
knowledge  acquired  in  school,  is  often  remembered  with  quite 


I 


DEMENTIA    PRECOX.  1 45 

remarkable  accuracy.  Whole  tables  of  matter,  learned  by- 
rote,  can  be  repeated,  and  often  this  ability  constitutes  a  strik- 
ing feature  of  the  case  when  the  dementia  has  become  pro- 
found, and  this  symptom  is  perhaps  about  the  only  one  left 
to  indicate  that  the  patient  was  ever  possessed  of  normal  mental 
faculties. 

Perhaps  as  characteristic  of  these  cases  as  the  disorder  of  v* 
attention  is  the  emotional  deterioration  which  they  exhibit. 
It  is  this  symptom  which  is  largely  responsible  for  their  indif- 
ference and  lack  of  interest  already  mentioned.  The  expres- 
sions of  joy  or  sorrow,  if  they  occur  at  all,  are  shallow  and  of 
short  duration.  A  death,  a  birth,  a  marriage,  the  visit  of  a 
long  absent  relative,  are  all  apprehended  with  the  same  lack 
of  emotional  impression.  No  matter  how  much  pleasure  or 
pain  the  event  might  be  supposed  to  give,  or  would  give  in  a 
normal  person,  the  patient  receives  it  with  indifference,  with- 
out surprise,  without  an  expression  of  interest  often,  in  the 
most  matter  of  fact  sort  of  way,  as  if  such  things  were  occur- 
ring hourly. 

We  find  a  similar  condition  of  affairs  in  the  intellectual 
domain.  The  ideas,  the  content  of  thought,  show  a  shallow- 
ness indicating  an  intellectual  enfeeblement.  Aside  from  the 
fact  that  the  fantastic,  unusual,  bizarre  character  of  the  delu- 
sions indicate  the  demented  groundwork  on  which  they  are 
founded,  the  patients  make  little  or  no  effort  to  support  their 
false  beliefs,  show  absolutely  no  insight  into  their  condition, 
and  make  the  most  manifestly  absurd  statements  often  in  the 
midst  of  a  fairly  coherent  conversation  without  at  all  appre- 
ciating the  incongruity.  Thus,  one  patient  was  able  to  an- 
swer questions  bearing  on  history  quite  well,  but  when  asked 
for  some  explanation  as  to  his  belief  that  the  electric  lights 
were  burning  holes  in  him  replied  by  saying,  "  They  are  pretty 
good  people  anyway."  The  same  patient  had  the  delusion 
that  he  had  no  eyes  or  hands.  Usually  when  questioned  about 
such  evident  absurdities  no  explanation  is  vouchsafed  and  the 
patient  retires  behind  the  reply,  "  I  don't  know."     The  dilapi- 


146  OUTLINES    OF    PSYCHIATRY, 

dation-  of  thought  becomes  more  and  more  manifest  as  demen- 
tia progresses,  leading  finally  in  its  expression  to  almost  com- 
plete incoherence,  as  shown  in  the  following  example : 

"  Oh,  yes,  indeed,  that  the  weather  and  condition  of  such 
become  rainy  and  people  dying,  and  the  worms  eat  the  bodies 
up  and  take  them  from  their  coffins,  they  would  not  allow  you 
to  disclose  the  bodies,  because  the  overflow  of  saliva  causes 
the  disease  by  which  people  cannot  exist.  Well,  I  am  the  only 
King  over  in  Ireland.  I  do  not  know  where  he  has  gone. 
They  wanted  to  put  me  in  a  wash-tub  and  everything  else. 
They  do  not  know  what  I  am,  do  you  see?  They  come  into 
a  saloon,  but  they  will  not  give  you  anything  to  drink.  I  was 
the  bartender  there.  I  am  a  stranger.  People  kill  them,  but 
they  come  to  life  again.  They  take  the  position  of  strangers 
when  they  leave  their  happy  homes,  but  I  do  not  understand 
how  they  could  kill  a  woman  outright.  What  right  have  you 
got  to  take  a  stranger  when  they  are  in  their  rightful  homes? 
This  is  the  post  of  duty  where  men  of  enlistment  return  to 
their  happy  homes.  This  is  the  post  of  duty  to  enter  not. 
They  must  be  prisoners.  They  do  not  get  out  of  sight.  Dr. 
Hogan  is  a  doctor  for  the  purpose  of  curing  people;  also  Dr. 
Burns;  where  they  are  going  I  know  not.  Well,  I  tell  you, 
doctor,  I  suffered  terribly  this  winter,  also  on  post  of  duty.  I 
do  not  know  anything  at  all  about  it,  but  there  is  an  illustration 
there.  I  cannot  blame  the  band  while  at  school  about  their 
music.  That  thermometer  there  is  to  tell  whether  you  live  or 
die,  and  it  becomes  such  a  dangerous  position  that  the  enemies 
approaching  at  this  post  of  duty,  I  cannot  do  it  with  the  light. 
That  man  escaped.  He  is  living  at  his  home  in  Binghamton, 
N.  Y,  Where  I  know  not.  I  know  that  his  name  is  Irish, 
They  will  not  take  him  to  his  rightful  home  in  the  condition 
of  such  by  which  he  has  no  means  of  support  by  attending  bar, 
I  was  kidnapped  upon  the  ocean,  and  taking  en  route  to  this 
place  I  know  not.  Well,  as  I  was  going  to  tell  you,  I  am  the 
enemy  himself.  These  people  here  cannot  perform  an  opera- 
tion.    They  do  not  know  what  they  are.     Well,  do  you  know 


DEMENTIA    PRECOX.  147 

me!  I  am  the  King  of  Ireland,  and  also  of  all  countries  in 
existence.  I  was  the  fellow  that  killed  the  Queen.  I  do  not 
know  who  she  was.  I  got  the  picture  of  him.  His  last  name 
was  Duffy.     I  cannot  get  in  communication  with  him." 

In  this  example  the  incoherence  reaches  a  very  high  degree, 
the  conversation  becomes  a  mere  "word  salad/'  in  which  it  is 
only  possible,  here  and  there,  to  pick  out  an  association,  and 
that  only  of  superficial  character. 

Physical:  These  patients  usually  emaciate  during  the  early 
stages  of  the  disease,  anorexia  and  insomnia  are  common,  cir- 
culatory disturbances,  rapid  cardiac  action,  and  cyanosis  of  the 
extremities  are  often  seen,  as  is  also  dermographia,  the  result 
of  vaso-motor  paralysis.  The  deep  reflexes  are  exaggerated 
and  the  pupils  quite  commonly  widely  dilated.  Epileptiform, 
and  especially  hysteriform,  attacks  are  quite  frequently  ob- 
served in  the  early  stages. 

In  describing  the  varieties  of  dementia  precox  they  will  be 
considered  under  five  heads :  ( i )  The  simple  dementia,  or 
heboidophrenia  of  Kahlbaum;  (2)  Hebephrenia;  (3)  Cata- 
tonia; (4)  Paranoid  Forms;  (5)  Mixed  Forms. 

I.     Simple  Dementia  (Heboidophrenia). 

In  accordance  with  the  conception  of  dementia  precox  out- 
lined above,  which  regards  it  as  primarily  a  dementia  upon 
which  various  psychotic  symptoms  may  be  engrafted,  this 
variety  would  constitute  the  typical,  fundamental  form  of  the 
disease,  showing  the  development  of  the  dementia  per  se,  with 
few  if  any  of  the  extraneous  symptoms  found  in  abundance  in 
some  of  the  other  forms. 

The  origin  of  this  variety  is  insidious,  and  it  may  be  quite 
impossible  to  fix  its  date,  largely  because  at  first  the  begin- 
ning symptoms  were  not  appreciated  at  their  true  value.  The 
young  boy,  or  girl,  as  the  case  may  be,  quite  commonly  was 
previous  to  the  onset  of  symptoms,  getting  on  nicely  in  school, 
perhaps  unusually  well,  was  quite  a  favorite  with  the  other 
pupils,  took  an  active  interest  in  school  life,  and  was  going  on 


148  OUTLINES   OF    PSYCHIATRY. 

with  the  young  people  of  the  neighborhood,  being  in  every 
way  considered  a  bright  and  normal  child. 

At  first  the  patient  begins  to  show  a  lack  of  interest  in 
things,  ceases  going  out  and  associates  less  and  less  with  other 
children.  There  is  a  general  listless,apparently  lazy  and  tired- 
out  attitude  towards  life  assumed,  lessons  are  neglected  and 
not  learned,  and  in  school  the  patient  shows  a  failing  ability  to 
assimilate  new  facts — to  acquire  knowledge. 

This  state  of  affairs  is  associated  with  insomnia  and  often 
headache,  sometimes  hysteriform  attacks,  and  not  infrequently 
is  mistaken  for  neurasthenia,  or,  if  the  patient  is  quite  inactive, 
this  inactivity  is  taken  to  be  an  expression  of  the  depression 
of  melancholia. 

Transitory  delusions  may  occur,  which  are  fully  expressed, 
and  fleeting  hallucinations  may  at  times  occupy  the  field. 
These  manifestations  are  usually  disagreeable,  voices  are  heard 
saying  disagreeable  or  insulting  things,  visions  of  the  devil 
occur,  and  the  like. 

Not  infrequently  these  patients  show  themselves  to  be  quite 
irritable,  and  partly  as  a  result,  there  may  occur  transitory 
excitements.  If,  in  addition,  peculiarities  of  conduct  and 
strange  habits  develop,  the  desire  to  be  alone,  some  mannerism, 
or  slight  evidences  of  muscular  tension  and  the  simpler  mani- 
festations of  negativism,  the  close  relation  between  these  and 
the  more  frequent  and  more  fully  developed  varieties  is  shown. 

II.     Hebephrenia. 

This  form  of  dementia  precox  is  usually  of  more  abrupt 
onset  than  the  last,  although  here  we  may  also  find  that  the 
prodromal  period  extends  over  several  months,  during  which 
time  the  patient  suffers  from  insomnia,  headache,  anorexia, 
and  perhaps  some  loss  of  flesh. 

The  symptoms  of  the  onset  of  the  attack  are  quite  generally 
confusion  and  symptoms  of  depression  which  have  an  outward 
semblance  to  the  symptoms  of  melancholia.  The  character- 
istic   retardation    of    manic-depressive    insanity    is,    however. 


1 


DEMENTIA    PRECOX.  149 

absent,  and  hallucinations  and  delusions  occupy  a  much  more 
prominent  place  in  the  picture.  These  hallucinations  are 
numerous  and  involve  more  especially  the  auditory  and  visual 
fields.  Both  hallucinations  and  delusions  are  disagreeable. 
Voices  are  heard  calling  vile  names  and  accusing  the  patient 
of  immoral  practices ;  delusions  are  self-accusatory  and  in  har- 
mony with  the  depression,  the  patient  thinks  he  is  lost  for 
having  masturbated  and  the  like.  In  this  condition  violent 
attempts  at  suicide  are  not  infrequent  and  only  go  to  add  force 
to  the  diagnosis  of  melancholia  so  often  made  at  this  stage  of 
the  disease. 

After  the  active  symptoms  of  the  first  stages  are  passed  the 
underlying  and  fundamental  defect  becomes  more  apparent. 
The  hallucinations  are  fleeting,  the  delusions  not  firmly  fixed 
but  changeable  and  fantastic  or  silly  in  content,  though  often 
with  a  paranoid  tinge;  thus  one  patient  believes  the  sheets 
stick  to  his  feet,  another  that  this  is  the  "wandering  planet." 
These  delusions  are  not  supported  by  reason  or  logic,  and  seem 
not  to  have  been  at  all  assimilated  to  the  mentality  of  the 
patient.  They  are  false  ideas,  disconnected  from  the  general 
content  of  thought  and  existing  much  as  do  foreign  bodies  in 
various  anatomical  locations. 

The  emotional  deterioration  is  prominently  in  evidence. 
One  patient  says  enemies  are  following  him,  and  that  he  has 
been  killed  a  number  of  times ;  another  that  the  other  patients 
are  trying  to  injure  him.  These  facts  are  told  with  no  show 
of  emotion,  in  a  decidedly  matter  of  fact  way. 

In  the  cases  that  are  not  profoundly  demented  a  certain 
looseness  of  the  train  of  thought  is  noticeable.  One  patient 
tells  me  that  he  has  been  ordained  by  the  Lord  to  preach — 
that  we  are  all  put  here  to  do  the  best  we  can — that  the  bread 
in  the  hospital  is  impure — that  he  enlisted  on  a  certain  date 
in  a  certain  regiment — that  when  he  first  came  to  the  hospital 
he  was  not  well  in  mind  or  body,  etc.  This  superficiality 
resembles  flight  of  ideas,  but  there  is  none  of  the  pressure  of 
activity  of  manic-depressive  insanity,  and  while  the  changes  in 


150  OUTLINES    OF    PSYCHIATRY. 

direction  of  the  train  of  thought  are  abrupt,  they  are  not 
sudden,  and  the  degree  of  incoherence  is  much  greater.  The 
speech  is  dehberate  and  there  does  not  appear  to  be  any  dis- 
tractibihty.  The  condition  is  due  rather  to  loose  connection 
between  the  elements  in  the  train  of  thought  and  to  poverty  of 
ideas.  In  some  of  the  more  excited  phases  of  dementia  precox 
we  do  find  a  close  resemblance  to  flight  of  ideas  and  these  are 
often  difficult  to  differentiate  from  manic-depressive  insanity. 

These  cases,  like  the  cases  of  heboidophrenia,  often  exhibit 
peculiar  habits  and  mannerisms — a  tendency  to  repeat  certain 
phrases,  suggestibility,  unusual  attitudes,  or  a  certain  muscular 
tension,  shown  by  angularity,  clumsiness,  and  restraint  in  their 
movements.  Annong  these  symptoms  is  often  noted  a  silly 
laugh  which  is  frequently  developed  while  the  patient  is  talk- 
ing to  himself,  out  which  may  occur  at  any  time  with  abso- 
lutely no  apparent  cause.  If  the  patient  is  asked  for  an  expla- 
nation of  why  lie  laughed  he  will  reply  in  a  characteristic 
manner,  "  I  don'ft  know,"  or  else  give  some  shallow,  wholly 
inadequate,  or  manifestly  false  reason.  These  various  symp- 
toms, with  the  exq^ption  perhaps  of  the  silly  laugh,  all  go  to 
show  the  fundamental  alliance  between  this  form  of  dementia 
precox  and  the  catatonic  variety  next  to  be  described. 

In  conduct  these  patients  usually  exhibit  a  condition  of  list- 
lessness,  apathy  and  disinterestedness  with  little  tendency  to 
activity  or  to  emotional  expression.  Alternating  conditions  of 
depression  and  excitement  may  and  often  do  occur  and  occa- 
sionally the  disease  is  ushered  in  by  an  excitement  which  may 
lead  to  a  diagnosis  of  mania,  as  the  opposite  onset  we  have 
seen  may  lead  to  a  diagnosis  of  melancholia. 

The  alternating  conditions  may  be  very  mild  as  in  the  case 
of  the  young  soldier  mentioned  above,  who  thought  he  was 
ordained  to  preach  and  that  the  bread  was  impure,  who  will 
be  quiet  for  several  months  and  then  exhibit  the  opposite  con- 
dition for  a  few  days  by  following  the  doctors  and  nurses 
about  the  ward  telling  them  his  troubles.  On  the  contrary, 
the  alternations  may  be  between  conditions  much  more  ex- 


DEMENTIA    PRECOX.  1$^ 

treme  as  in  the  case  of  the  patient  who  alternates  between  a 
state  of  stupor  and  a  state  of  excitement,  in  which  he  eats 
paper,  strings,  sticks,  and  bedecks  himself  with  all  sorts  of 
trash  he  collects  for  that  purpose,  at  times  becoming  violently 
angry  and  cursing  every  one.  This  more  marked  alternation 
is,  however,  somewhat  more  characteristic  of  catatonia. 

In  these  excited  conditions  in  cases  in  which  dementia  is 
well  marked  the  form  of  thought  becomes  greatly  deranged, 
and  there  is  a  high  grade  of  incoherence  amounting  to  confu- 
sion of  thought  and  the  speech  shows  absolute  incoherence,  a 
mere  jumble  of  words  expressing  only  fragments  of  ideas.  A 
veritable  word-salad  (Salade  de  mots  of  Forel). 
The  following  is  a  stenogram  from  such  a  case : 
"How  old  are  you?"  "Why,  I  am  centuries  old,  sir." 
"  How  long  have  you  been  here?  "  "  I  have  been  now  on  this 
property  on  and  off  for  a  long  time.  I  cannot  say  the  exact 
time,  because  we  are  absorbed  by  the  air  at  night,  and  they 
bring  back  people.  They  kill  up  everything;  they  can  make 
you  lie;  they  can  talk  through  your  throat."  "  Who  is  this?  " 
"  Why  the  air?  "  "  What  is  the  name  of  this  place?  "  "  This 
place  is  called  a  star."  "  Who  is  the  doctor  in  charge  of  your 
ward ? "  "A  body  just  like  yours,  sir.  They  can  make  you 
black  and  white.  I  say  good  morning,  but  he  just  comes 
through  there.  At  first  it  was  a  colony.  They  said  it  was 
heaven.  These  buildings  were  not  solid  at  the  time,  and  I  am 
positive  this  is  the  same  place.  They  have  others  just  like 
it.  People  die  and  all  the  microbes  talk  over  there,  and  pres- 
tigitis  you  know  is  sending  you  from  here  to  another  world." 
"Do  you  know  what  year  this  is?"  "Why  centuries  ago." 
"  Do  you  know  who  discovered  America  ?  "  "  Yes,  sir ;  Co- 
lumbus." "What  year?"  "1492.  They  have  had  several 
discoveries  since  then,  sir."  "When  was  the  Civil  War?" 
"That  was  in  1864-1860-1864."  "Who  was  the  President 
of  the  United  States  at  that  time  ?  "  "  Well,  let  me  see ;  they 
make  you  over  again,  sir."  "  When  did  you  enter  the  army  ?  " 
"  I  entered  the  army,  why  it  was  centuries  and  centuries  ago; 


152  OUTLINES   OF    PSYCHIATRY. 

not  I  but  a  body  just  like  my  remembrance,  around  1903." 
"  Were  you  ever  in  Cuba  ?  "  "  Yes,  sir ;  I  was  there  three 
times.  That  was  centuries  ago;  not  I  but  my  remembrance, 
because  I  have  been  killed ;  yes,  I  have  been  killed,  I  am  posi- 
tive of  that.  Over  there  originally — originally  means  first — 
they  re-make  us.  There  are  other  stars  like  this.  I  was  sent 
by  the  government  to  the  United  States  to  Washington  to 
some  star,  and  they  had  a  pretty  nice  country  there.  Now 
you  have  a  body  like  a  young  man  who  says  he  is  of  the  pres- 
tigitis."  "  Who  was  this  prestigitis?  "  "  Why  you  are  your- 
self. You  can  be  a  prestigitis.  They  make  you  say  bad 
things;  they  can  read  you;  they  bring  back  negroes  from  the 
dead." 

III.     Catatonia. 

Like  the  other  forms  of  dementia  precox  which  have  been 
described  this  form  is  usually  of  sub-acute  or  chronic  onset, 
being  preceded  by  symptoms  of  insomnia,  confusion,  headache, 
loss  of  appetite,  emaciation  and  the  like.  The  disease,  on  the 
contrary,  is  sometimes  of  sudden  onset,  in  which  case  it  is  apt 
to  be  the  result  of  a  suddenly  depleting  cause  like  the  loss  of 
blood  or  some  severe  emotional  shock  or  fright.  In  these 
cases  the  patient  may  become  at  once  profoundly  stuporous. 

The  initial  stages  are  usually  marked  by  a  mild  grade  of 
depression,  as  in  other  forms,  giving  the  appearance  of  melan- 
cholia. Hysterical  attacks  and  in  some  cases  epileptiform  con- 
vulsions may  occur  during  this  period. 

Following  the  more  or  less  vague  symptoms  of  the  pro- 
dromal period  occur  the  typical  symptoms  of  the  disease  which 
group  themselves  into  two  stages  which  irregularly  alternate, 
viz.,  catatonic  stupor  and  catatonic  excitement. 

In  catatonic  stupor  the  principal  symptoms  are  stupor,  nega- 
tivism and  muscular  tension.  In  the  extreme  cases  the  pa- 
tient lies  perfectly  still,  without  making  any  movement  what- 
ever and  not  reacting  at  all  to  stimuli.  Questions  are  paid  no 
attention  to  whatever,  absolute  mutism  being  the  rule,  while 


DEMENTIA    PRECOX.  153 

sensory  stimuli  of  very  considerable  strength  may  be  applied 
without  eliciting  any  response. 

The  mutism  is  one  of  the  manifestations  of  negativism 
which  usually  shows  itself  in  various  ways.  The  patient  not 
only  refuses  to  eat,  but  pays  no  attention  to  the  calls  of  nature, 
permitting  the  bladder  and  rectum  to  become  overloaded  with 
urine  and  fsecal  matter,  often  to  a  serious  extent;  he  likewise 
allows  the  saliva  to  collect  in  his  mouth  for  hours  at  a  time 
until  putrefactive  changes  have  occurred,  and  then  only  perhaps 
as  a  result  of  insistence  by  the  nurse  belches  forth  this  mass  of 
stinking  fluid.  Any  effort  to  get  the  patient  to  do  anything 
is  immediately  met  by  a  response  diametrically  opposed  to  the 
desired  act.  If  asked  to  show  the  tongue  the  lips  are  tightly 
closed;  if  asked  to  open  the  eyes  they  are  closed,  if  already 
open,  or,  if  closed,  the  lids  are  pressed  more  tightly  together 
by  the  orbicularis. 

Attempts  to  move  the  body  are  met  by  marked  resistance 
and  elicit  the  condition  of  muscular  tension.  The  limbs  are 
quite  rigid,  often  stretched  out  stifily,  the  fist  perhaps  tightly 
clenched,  or,  again,  the  extremities  of  the  body  as  a  whole, 
perhaps,  may  rigidly  occupy  some  peculiar  position.  This 
muscular  tension  is  often  shown  in  grimaces,  certain  facial 
muscles  continuing  in  contraction  and  giving  strange  and  pecu- 
liar expressions  to  the  countenance.  Thus  we  find  that  the 
patient  maintains  a  constant  expression  of  scowling,  or  keeps 
the  eyes  tightly  closed,  the  cheeks  puffed  out,  or  perhaps  the 
lips  closed  and  protruded,  producing  the  condition  called  by  the 
Germans  "  Snautzkrampf." 

Quite  the  reverse  of  this  picture  of  negativism  and  muscular 
tension  is  seen  in  other  cases.  In  the  place  of  muscular  tension 
we  find  a  condition  of  remarkable  flexibility,  so  that  the  limbs 
may  be  molded  into  any  position  desired,  and  though  quite 
unusual,  they  are  maintained  there  indefinitely — catalepsy — if 
raised,  until  gravity  and  fatigue  cause  them  to  fall.  This  con- 
dition is  known  as  flexibilitas  cerca  (waxy  flexibility). 

With  this  condition  is  also  found  the  opposite  state  of  nega- 


154  OUTLINES    OF    PSYCHIATRY. 

tivism,  namely,  suggestibility  or  command  automatism.  Pa- 
tients in  this  condition  do  mechanically  just  what  they  are  told. 
This  condition  of  heightened  suggestibility  may  be  so  marked 
as  to  produce  echolaUa — a  repetition  of  words  and  phrases 
spoken  to  them,  and  echopraxia — a  repetition  of  movements  in 
their  presence.  These  symptoms  are  often  noted  during  the 
examination,  when  it  is  observed  that  the  questions  of  the 
examiner  are  repeated  by  the  patient — in  whole  or  in  part — 
and  that  also  many  of  his  movements  may  also  be  repeated, 
such,  for  example,  as  looking  at  his  watch,  putting  the  hand 
to  the  face,  and  the  like. 

The  condition  of  catatonic  stupor  alternates  with  catatonic 
excitement.  Here  we  find  symptoms  manifesting  themselves 
by  activity  as  opposed  to  the  general  condition  of  passivity  or 
quiescence  in  the  stuporous  patients. 

The  marked  cases  of  catatonic  excitement  are  constantly 
talking,  shouting,  throwing  themselves  about  on  the  bed,  and 
generally  manifesting  a  condition  of  increased  psychomotor 
activity,  reminding  one  very  much  at  first  of  the  manic  stage 
of  manic-depressive  insanity.  The  actions  are,  however,  much 
more  absurd,  not  directed  consistently  to  any  end,  quite  inco- 
herent and  often  interrupted  by  attitudinizing,  hysteriform 
attacks  and  stereotyped  movements — the  patients  repeating 
over  and  over  again  certain  motions,  such  as  swaying  the  body 
backwards  and  forwards,  nodding  the  head,  swinging  the 
arms  or  certain  other  motions  characteristic  of  the  patient  and 
which  have  no  apparent  significance.  These  motions  are  often 
accompanied  by  some  sound,  such  as  a  grunt  or  blowing  sound, 
or  by  the  continuous  repetition  of  some  phrase. 

Verbigeration,  often  associated  with  senseless  rhyming,  is 
quite  common.     The  following  is  an  example : 

"What  is  your  name?"  "How  old  are  you?"  "About 
thirty."  "How  long  have  you  been  here?"  "A  couple  of 
years."  "  What  do  you  do  most  of  the  time?  "  "  Fold  shirts 
in  the  laundry  and  mend  the  clothes."  "  Do  you  talk  to  your- 
self?"    "I  do  not  talk  to  myself;  talk  to  other  people,  also 


DEMENTIA    PRECOX.  155 

talk  to  all  the  people  I  run  across."  "What  do  you  talk 
about  ?  "  "  Talk  about  the  weather,  etc."  "  What  is  that  you 
say  to  yourself?"  "Locks  and  keys,  keys  and  locks,  locks, 
keys,  keys,  locks,  locks,  locks,  keys;  just  a  sort  of  doggerel 
[perseveration].  You  know  some  of  the  attendants  might 
get  hold  of  me  and  punch  me.  Locks,  keys,  keys,  locks,  locks, 
keys,  keys,  locks.  You  know  if  they  was  to  run  across  me 
making  too  much  noise  they  might  hurt  me."  "  What  do 
you  say  locks  and  keys  for?"  "Just  to  enjoy  myself.  You 
know  there  are  times  when  there  is  nothing  doing,  and  I  have 
to  do  it  to  pass  away  the  time,  and  you  might  just  as  well  say 
something  as  nothing."  "  What  did  you  say  the  other  night 
to  the  students  ?  "  "  Told  them  about  locks  and  keys."  "What 
else?"  "Myriads  of  us  keep  growing  in  numbers,  also  in 
largenesses ;  locks  and  keys,  keys,  locks,  locks,  keys,  keys,  locks, 
locks,  keys,  keys,  locks.  Myriads  of  us  quick-foot  full  through, 
ev-er  no  mat-ter.  Locks,  keys,  keys,  locks,  locks,  keys,  keys. 
Myriads  of  us  ev-er  full  us  as  keep  lives  giant's  growths,  ev-er 
lives  giant's  keeper,  ev-er  no  mat-ter.  Locks,  keys,  keys,  locks, 
locks,  keys,  keys,  locks.  Lives  giant's  wealth,  health  and 
pleasures,  ev-er  no  mat-ter.  Lives  sweet  foreigners,  ev-er  no 
mat-ter."  "Can't  you  recite  some  more  poetry?"  "I  can- 
not give  any  more;  locks,  keys,  keys,  locks,  locks,  keys,  locks. 
Me  don't  know  any  more ;  locks,  keys,  keys,  locks,  locks,  keys. 
I  will  get  in  trouble.  I  have  been  raking  away  at  it  outside 
ana  in  and  inside  out  again.  I  have  tried  to  write  poetry,  but 
could  not  write  any  more  than  six  fools." 

The  noisy  incoherent  talk  of  these  cases  might  readily  be 
thought  to  indicate  flight  of  ideas  but  the  incoherence  is  much 
greater  than  that  found  with  an  equal  grade  of  agitation  in 
manic-depressive  insanity,  and  there  is  no  trace  of  a  guiding 
thought  in  the  form  of  a  goal  idea.  The  patient,  too,  does  not 
show  distractibility  to  the  same  extent,  being,  on  the  contrary, 
quite  inaccessible,  paying  no  attention  whatever  to  what  is 
being  said  or  done  by  others,  not  even  making  any  pretense  to 
answer  questions,  though  often  repeated. 


156  OUTLINES   OF    PSYCHIATRY. 

y.  Quite  characteristic  of  this  condition,  too,  are  the  impulsive 
acts  of  these  patients.  They  will  suddenly  and  with  absolutely 
no  warning  whatever  commit  some  act  of  violence,  such  as 
assaulting  another  patient  or  breaking  out  a  window,  and  quite 
as  suddenly  lapse  into  their  previous  state.  It  is  quite  impos- 
sible to  get  any  adequate  information  as  to  the  cause  for  these 
acts.  The  patient  is  inaccessible  to  a  degree  and  either  gives 
some  senseless  reply  to  the  questions  asked,  a  puerile  reason, 
perhaps,  or  retires  behind  an  "  I  don't  know "  or  complete 
silence.  These  attacks  come  out  of  clear  sky,  cannot  be  fore- 
seen, and  make  these  patients  at  times  very  dangerous. 

In  the  milder  cases  of  catatonic  excitement,  in  which  the 
motor  excitement  is  not  so  pronounced,  the  patients  are  quite 
commonly  characterized  by  the  development  of  certain  habits 
of  action  in  some  definite  particular.  These  peculiarities  are 
known  as  mannerisms.  One  patient  must  slide  the  right  foot 
backward  and  forward  before  beginning  to  walk,  another  holds 
the  fork  in  a  peculiar  way,  another  walks  close  to  the  wall,  not 
coming  out  into  the  center  of  the  ward,  another  carefully  avoids 
stepping  on  cracks  in  the  sidewalk,  and  so  on  indefinitely. 

Physical  Symptoms. — The  physical  symptoms  of  catatonia 
are  much  more  prominent  than  in  any  other  form  of  dementia 
precox. 

Slight  differences  in  the  size  of  the  pupils  is  common.  Pu- 
pillary unrest  (hippus)  is  sometimes  observed;  quite  frequently 
a  marked  degree  of  mydriasis  is  present,  while  the  phenomenon 
of  Pilz  is  sometimes  found.  The  tendon  reflexes  are  usually 
exaggerated.  The  cutaneous  sensibility  is  lowered.  Vaso- 
motor disturbances  are  often  seen,  giving  rise  to  cold,  cyanosed 
extremities  in  the  stuporous  cases.  With  this  condition  may 
be  associated  dermographia.  The  secretions  are  disturbed,  the 
sweat  and  saliva  may  be  increased,  the  urine  scanty  or  in- 
creased, and  constipation  may  prevail.  Loss  of  weight  is 
common  in  the  active  stasfes  of  this  disease. 


DEMENTIA    PRECOX.  157 

IV.     Paranoid  Forms. 

There  has  been  a  great  deal  of  discussion  as  to  just  what 
cases  are  properly  included  under  this  heading.  It  is  inevi- 
table, as  long  as  paranoia  itself  is  so  poorly  defined,  that  the 
paranoid  forms  of  mental  disease  should  also  be  difficult  to 
classify. 

The  fundamental  fact  is  that  we  find  here,  in  dementia 
precox,  cases  presenting  the  paranoid  syndrome — delusions  of 
persecution  or  grandeur,  somewhat  systematized,  with  perhaps 
hallucinations  of  hearing. 

The  difficulty  is  that  some  writers  object  to  the  inclusion  of 
certain  forms  in  the  category  of  dementia  precox,  others  ques- 
tion the  propriety  of  the  inclusion  of  the  same  forms  under  the 
head  of  paranoia. 

If  dementia  precox  is  to  be  considered  as  fundamentally  a 
deterioration  psychosis,  then  we  must  expect  to  find  symptoms 
of  dementia  associated  with  the  paranoid  syndrome.  Kraepe-  v^ 
lin,  however,  has  included  cases  that  develop  late  in  life,  after 
thirty,  and  maintain  their  intellectual  integrity  for  years  before 
signs  of  dementia  appear.  On  the  other  hand,  it  may  be 
argued  that  the  clearest  cases  of  paranoia  present  evidences  of 
intellectual  impairment.  The  delusional  system  which  these 
patients  build  up  is  founded  upon  ideas  which  have  no  answer- 
ing facts  in  actual  experience,  and  to  be  consistently  maintained 
the  patient  must  be  afflicted  with  serious  defect  of  judgment. 
Now,  judgment  is  a  function  of  the  intellect,  so  that  a  defect 
of  judgment  presupposes  an  impairment  of  the  intellect.  Can 
not  this  impairment  be  properly  regarded  as  the  earliest  sign 
of  a  dementia?  Is  there  any  essential  difference  other  than 
one  of  degree  between  the  patient  who  believes  his  food  to  be 
poisoned  and  the  patient  who  maintains  that  he  has  no  hands? 
Is  not  the  fantastic,  absurd  nature  of  the  delusion  simply  a 
measure  of  the  intellectual  impairment?  The  delusion  of  poi- 
soning is  just  as  far  removed  from  facts  and  has  no  more 
foundation  in  experience;  it  is,  however,  more  probable,  less 


158  OUTLINES    OF    PSYCHIATRY. 

absurd,  presents  fewer  unusual  features,  because  the  judgment 
is  not  so  seriously  impaired.  The  whole  case,  from  the  intel- 
lectual standpoint,  would  appear  to  be  one  of  degree. 

The  difficulty  of  differentiating  the  conditions  in  their  early 
stages  is  often  very  great  if  not  quite  impossible.  Now  that 
we  no  longer  consider  paranoia  a  purely  intellectual  disorder 
we  know  that  its  early  stages  are  usually  marked  by  emotional 
depression.  We  find  this  same  condition  of  emotional  depres- 
sion in  the  prodromal  period  of  dementia  precox.  If,  then,  we 
find  a  boy  eighteen  or  twenty  years  old  with  a  fairly  well 
organized  delusional  system  and  markedly  depressed,  with  little 
or  no  evidences  of  intellectual  impairment,  perhaps  only  a  de- 
sire to  seclude  himself,  with  an  apparent  inability  to  apply  his 
mind  consistently  to  any  end,  it  is  practically  impossible  to  say 
whether  we  are  dealing  with  a  case  of  incipient  paranoia  or  of 
dementia  precox. 

When,  however,  we  find  a  case  which  gives  a  history  of  a 
comparatively  acute  onset,  with  the  usual  symptoms  of  insom- 
nia, depression,  loss  of  appetite  and  some  emaciation;  and  an 
examination  reveals  a  loosely  organized  delusional  system,  the 
delusions  of  which  are  numerous,  fantastic  and  often  change- 
able, associated  with  numerous  fleeting  hallucinations,  we  may 
feel  confident  that  we  are  dealing  Avith  a  case  of  dementia 
precox.  This  diagnosis  is  especially  warranted  if  in  addition 
to  the  above  symptoms  evidences  of  muscular  tension,  stereo- 
topy,  verbigeration,  automatism,  mannerisms,  suggestibility  or 
negativism  are  found,  these  symptoms,  as  we  have  seen, 
being  found  in  all  the  varieties  of  dementia  precox  in  varying 
degrees  and  combinations,  and  seeming  to  show,  as  does  de- 
mentia, the  underlying  unity  of  the  several  different  forms. 

The  following  case  shows  very  well  the  mental  symptoms  of 
paranoid  dementia,  although  the  physical  symptoms,  except 
perhaps  the  dilated  pupils,  are  absent.  The  delusions,  which 
were  more  truly  of  the  paranoid  variety  at  first,  were  of  rapid 
growth ;  they  soon  became  tinged  with  the  absurd  and  bizarre, 
with  deepening  defect,  while  the  emotional  reaction  was  prac- 


DEMENTIA    PRECOX.  159 

tically  absent.  The  patient  has  some  appreciation  of  the  absurd 
character  of  his  ideas  and  fails  to  support  them  with  any  show 
of  logic,  resting  in  the  statement  that  they  are  facts. 

C.  R.  L.  Admitted  April  7,  1905.  Age,  2^  years.  Single. 
Nativity,  U.  S.  Family  history  is  unobtainable.  The  patient 
claims  his  physical  health  was  excellent  until  an  injury  he 
received  in  the  abdomen  eight  years  ago  by  a  falling  plank. 
Since  then  he  has  suffered  much  from  headaches.  According 
to  his  statement  in  the  summer  of  1903  he  was  accused  wrong- 
fully of  ruining  a  girl  and  was  tried  in  court  for  this.  He 
claims  he  was  compelled  to  forfeit  one  thousand  acres  of  land. 
This  property  was  sold  and  the  proceeds  were  turned  over  to 
the  mother  and  child.  Patient  asserts  that  the  girl's  mother 
was  the  cause  of  all  the  trouble,  as  she  was  jealous  of  him.  He 
says  since  this  affair  he  has  worried  greatly.  The  patient  en- 
listed in  the  Marine  Corps  after  this,  but  did  not  like  the  ser- 
vice because  his  comrades  made  things  very  unpleasant  for 
him.  They  were  jealous  of  the  position  he  held  as  hostler  to 
a  general  stationed  in  this  city.  These  men,  he  believes,  threw 
stones  at  him  in  the  dark,  and  on  one  or  two  occasions  they  put 
dead  men's  bones  and  dust  in  his  bed  at  night.  On  March  4th, 
one  month  before  his  admission  to  this  hospital,  he  was  kicked 
in  the  abdomen  by  a  horse  in  the  same  region  he  received  the 
wound  years  ago.  The  blow  from  the  animal  prostrated  him, 
and  he  was  sent  to  the  Naval  Hospital  in  this  city.  He  became 
melancholy  and  hypochondriacal,  and  was  admitted  to  this  in- 
stitution April  7,  1905. 

On  entrance  he  complained  of  fatigue,  and  was  put  to  bed. 
The  next  morning  he  asserted  he  slept  poorly  the  night  before 
on  account  of  a  severe  pain  in  his  back,  which  gradually  as- 
cended to  his  head,  and  by  the  time  it  reached  his  forehead  a 
peculiar  animal  appeared  before  him.  This  monster  was  white 
and  had  a  body  like  a  man,  with  the  feet  of  a  cow.  It  carried 
a  fierce  hook  on  the  end  of  its  tail  and  seemed  endeavoring 
to  strike  him  on  the  forehead  with  this  hook  in  the  region  of 
his  headache. 


l6o  OUTLINES    OF    PSYCHIATRY. 

The  patient  has  now  been  here  two  weeks.  He  is  oriented 
for  place  and  person,  but  as  to  time  he  is  quite  uncertain, 
memory  for  recent  events  and  dates  being  clouded.  He  gives 
the  month  and  its  date  incorrectly,  and  hesitates  over  the  events 
which  transpired  several  months  before  admission  here;  but 
for  the  correctness  of  dates  and  happenings  of  his  youth  and 
early  manhood  he  appears  confident. 

He  sits  about  the  ward  quietly,  orderly  and  disinterested, 
but  willingly  tells  the  doctor  of  his  wrongs.  These  are  cited 
in  a  drawling,  monotonous  voice.  Parts  of  the  persecutory 
side  to  his  history  appear  plausible,  but  the  ridiculous  side  is 
preeminent,  and  "  that  animal  with  the  body  of  a  man,  with  the 
legs  of  a  cow  "  appears  daily  now,  and  again  a  few  days  ago 
dead  men's  dust  and  bones  were  thrown  into  his  room.  He 
continues  hearing  these  strange  angry  voices,  which  seem  to 
come  through  the  radiator.  When  questioned  as  to  the  utter 
impossibility  of  such  an  animal  as  he  above  mentioned  being 
in  existence,  the  patient  laughed  and  exclaimed :  "  Indeed, 
doctor,  it  does  appear  silly  but  it  is  the  truth."  He  is  decid- 
edly hypochondriacal,  and  knows  that  he  has  catarrh  all  over 
his  body,  as  he  can  feel  it  in  his  finger-tips  and  he  knows  he 
caught  it  when  he  was  kicked  in  the  stomach  by  the  horse  a 
few  weeks  ago.  These  peculiar  pains  start  in  his  kidneys  and 
travel  up  to  his  brain  and  over  his  forehead,  and  sometimes  he 
is  so  nerv^ous  that  he  feels  that  he  would  like  to  jump  up  and 
scream.  He  says  the  doctors  are  wise,  but  they  don't  under- 
stand his  case.  The  patient  does  not  appear  alarmed  over  his 
ill  health,  however,  and  he  has  expressed  a  desire  to  go  away. 

Aside  from  the  large  cicatrix  on  his  abdomen  and  a  deform- 
ity from  a  broken  nose  received  years  ago,  physical  examination 
is  negative.  The  pupils  are  usually  dilated,  but  they  respond 
promptly  to  light  and  accommodation.  Speech,  coordination 
and  gait  show  no  disturbances,  and  tremors  are  absent.  The 
heart  and  lungs  appear  normal. 

In  some  of  these  paranoid  forms  the  hallucinations  play  a 
very  prominent  part;  in  others  they  are  less  significant.     The 


I 


DEMENTIA    PRECOX.  l6l 

delusions  are  not  infrequently  of  a  grandiose  nature  and  such 
patients  often  decorate  themselves  very  lavishly  with  all  sorts 
of  ornaments  and  insignia,  usually  made  by  themselves.  They 
are  the  cases  that  are  known  as  fantastic  paranoiacs. 

V.     Mixed  States. 

As  previously  mentioned  the  several  forms  described  are  not 
always  clean-cut.  The  simple,  hebephrenic  and  paranoid  often 
present  symptoms  that  are  more  characteristically  developed  in 
the  catatonic.  These  mixed  forms  are  in  reality  very  common 
indeed  and  in  fact  almost  constitute  the  rule. 

Course  and  Progress. — The  simple  and  paranoid  forms 
are  the  slowest  of  evolution  and  most  chronic  in  course,  the 
paranoid  forms  often  remaining  in  statu  quo  for  two  or  three 
years.  The  hebephrenic  and  catatonic  forms  are  more  acute 
in  onset  and  course,  leading  more  rapidly  to  dementia  in  the 
majority  of  cases,  although  the  catatonic  form  has  rather  the 
best  prognosis. 

Remissions  occur  especially  in  the  catatonics.  According  to 
Kraepelin,  8  per  cent,  of  the  hebephrenics  (including  the  group 
of  simple  dementia)  and  13  per  cent,  of  catatonics  make  prac- 
tical recoveries,  but  some  of  these  cases  relapse.  The  paranoid 
cases  do  not  get  well.  The  tendency  of  all  forms  is  to  a  grad- 
ually deepening  dementia. 

Diagnosis. — The  principal  difficulties  in  the  early  stages  are 
to  differentiate  from  the  depression  of  manic-depressive  insan- 
ity and  from  neurasthenia.  Time  may  be  necessary  in  order 
to  accomplish  this.  Later  the  euphoria  and  incoherence  may 
simulate  the  manic  state  of  manic-depressive  insanity.  The 
presence  of  symptoms  of  defect  will  make  the  diagnosis.  The 
excitement  of  catatonia  also  resembles  manic  excitement,  hut  in 
catatonic  excitement  the  degree  of  incoherence  is  out  of  all 
proportion  to  the  other  symptoms,  while  in  manic  excitement 
the  proportion  is  usually  maintained. 

The  epileptiform  and  hysteriform  attacks  may  lead  to  a  diag- 
nosis of  epilepsy  or  hysteria.  The  history  is  usually  sufficient 
to  prevent  this  mistake. 


l62  OUTLINES   OF    PSYCHIATRY. 

It  must  not  be  forgotten  that  catatonic  symptoms  may  ap- 
pear, though  usually  in  a  rudimentary  form  in  paresis,  senile 
dementia,  in  the  infection-exhaustion  psychoses,  and  even  in 
involution  melancholia. 

Pathology. — There  is  very  little  that  is  distinctive  in  the 
pathology  of  dementia  precox.  In  the  same  way  that  the  clin- 
ical symptoms  are  widely  diffused  and  rather  indefinite  so  it 
is  with  the  pathological  findings.  A  certain  amount  of  degen- 
erative changes  are  often  found  in  the  cortical  cells,  while  some 
observers  hold  that  these  cells  are  fewer  in  number  than  nor- 
mal. The  neuroglia  is  quite  frequently  found  increased  in 
amount.  In  the  other  organs  the  changes  are  inconsiderable. 
Beginning  degenerative  changes  may  be  found  in  the  vessels 
and  tuberculosis  is  not  an  infrequent  complication. 

Treatment. — The  treatment  must  be  entirely  symptomatic. 
A  careful  search  should  be  made  in  each  case  for  functional 
abnormalities  and  they  should  be  corrected  as  far  as  possible. 

These  cases  will,  of  necessity,  have  to  spend  most  of  their 
lives  in  a  hospital.  It  is  therefore  desirable  to  educate  them 
as  early  as  possible  in  good  habits.  They  should  be  encour- 
aged to  some  form  of  occupation,  preferably  out  of  doors. 
Under  the  influence  of  hospital  surroundings  and  farm  life 
these  cases  may  get  on  very  comfortably  and  the  dementing 
process  be  considerably  retarded. 


CHAPTER   XII. 
INVOLUTION   MELANCHOLIA. 

General  Considerations. — Under  the  influence  of  the  Ger- 
man school  the  term  melancholia  has  been  limited  to  the  depres- 
sions of  advanced  life  that  cannot  be  classed  with  any  of  the 
other  psychoses,  as  for  instance  manic-depressive  insanity.  The 
distinction,  in  the  main,  is  based  on  the  characteristic  appear- 
ance of  anxiety  and  the  equally  characteristic  absence  of  retar- 
dation. More  careful  observation,  however,  has  taught  us  that 
while  anxiety  is  quite  typical  of  the  depressions  of  advanced 
life,  it  does  occur  in  the  young,  while  retardation,  so  necessary 
a  part  of  the  picture  in  the  manic-depressive  type  of  depres- 
sion, is  also  found  in  the  melancholia  of  later  life.  We  are 
thus  rather  coming  to  a  belief  that  perhaps  the  differences  be- 
tween the  depressions  at  the  two  periods  of  life  are  after  all 
not 'fundamental  but,  to  an  extent  at  least,  dependent  upon  the 
conditions  incident  to  and  dependent  upon  age. 

The  various  depressions  that  cannot  be  classed  with  involu- 
tion melancholia  or  manic-depressive  insanity  and  do  not  form 
an  integral  part  of  any  other  psychosis,  but  which  are  the 
result  of  underlying  mental  or  physical  states  for  convenience 
are  designated  as  the  symptomatic  depressions. 

General  Characterization. — A  psychosis  of  the  involutional 
period  of  life  characterized  by  great  emotional  depression, 
apprehension  and  anxiety. 

Etiology. — Melancholia  is  essentially  a  disease  of  the  period 
of  involution — forty  to  fifty  years  in  women,  rarely  before  fifty 
in  men.  A  considerable  number,  but  by  no  means  all,  show 
the  beginning  of  senile  decay — gray  hair  and  the  early  changes 
of  arterio-sclerosis  being  most  noticeable.  The  menopause 
seems  to  be  an  important  etiological  factor  in  women.     Hered- 

163 


164  OUTLINES    OF    PSYCHIATRY. 

ity  does  not  play  as  important  a  role  here  as  in  some  of  the 
other  psychoses,  being  only  present  in  about  sixty  per  cent,  of 
the  cases.  Marked  exciting  causes,  such  as  emotional  shock, 
or  other  conditions  of  mental  stress  are  unusually  frequent. 
It  would  seem  that  this  class  of  causes  operating  upon  a  mind 
under  the  general  stress  of  the  involution  period,  and  perhaps 
the  additional  stress  of  heredity,  were  the  important  factors  in 
etiology. 

Symptomatology. — The  disease  commonly  has  a  prodro- 
mal period  of  several  months  duration.  The  symptoms  of  this 
period  are  indefinite  and  are  comprised  of  certain  head  symp- 
toms, such  as  pressure,  pain,  vertigo,  together  with  anorexia, 
irritability,  insomnia,  mental  insufficiency,  a  mild  neurasthenic 
state  and  some  emaciation. 

This  condition  becomes  progressively  worse  and  the  patients 
develop  a  morbid  fear  of  impending  danger — apprehensive 
depression.  The  morbid  background  for  this  depression  is 
not  infrequently  delusions  of  sin.  All  sorts  of  acts  in  the 
patient's  past  life  are  reviewed  and  considered  to  be  unforgiv- 
able sins.  Masturbation,  a  petty  theft,  the  failure  to  carry 
out  the  advice  of  a  priest,  in  fact  almost  anything  may  be 
looked  upon  as  a  terrible  sin,  even  magnified  into  the  unpar- 
donable sin,  and  the  patient  fears  his  soul  is  irretrievably 
lost,  that  he  will  go  to  hell  when  he  dies  and  suffer  its  torments 
eternally. 

The  fear  and  apprehension  from  such  causes  may  be  com- 
paratively slight  and  the  patient  show  no  outward  evidences  of 
it  except  in  conversation.  Under  these  circumstances  he  is 
quite  often  able  to  put  his  depression  in  the  background  and 
occupy  himself  with  some  form  of  work.  In  these  cases  con- 
sciousness is  unclouded,  orientation  is  unimpaired,  and  hallu- 
cinations, if  present,  take  a  minor  place  in  the  symptom- 
complex.  In  these  cases,  even  when  the  depression  is  consid- 
erably marked,  the  patients  are  quite  capable  of  seeing  a  joke 
and  the  lapse  into  a  moment  of  light  talk  and  the  smile  show- 


INVOLUTION    MELANCHOLIA.  165 

ing  forth  from  a  background  of  profound  depression  are  note- 
worthy and  characteristic. 

If  the  depression  becomes  more  marked  the  fear  and  appre- 
hension graduate  into  a  condition  of  anxiety.  The  patient 
goes  about  wringing  his  hands,  moaning  and  groaning,  perhaps 
repeating  over  and  over  again  some  such  phrase  as  Oh  my 
God !  Oh  my  God !  "  It  is  a  fearful  thing.  Good  Lord 
help  me ! "  The  fear  of  impending  danger  is  imminent,  the 
patient  is  lost  and  is  about  to  be  executed.  Whenever  the 
physician  visits  the  ward  he  is  believed  to  have  come  to  carry 
out  the  sentence  of  execution,  and  the  patient  begs  and  pleads 
to  be  spared,  not  to  be  taken  out  and  butchered,  shot,  and  cut 
up  into  little  pieces.  Reassurances  are  in  vain.  The  slam- 
ming of  a  door  in  an  adjoining  ward  is  the  report  of  a  gun — a 
patient  has  just  been  shot  and  they  are  coming  for  him.  These 
are  the  cases  of  agitated  melancholia. 

Even  in  these  cases  consciousness  remains  unclouded,  orien- 
tation is  little  if  at  all  impaired,  and  the  form  of  thought  is 
maintained. 

Quite  a  different  picture  is  sometimes  presented  by  patients 
with  symptoms  of  retardation.  The  milder  cases  merely  show 
slow  movements,  slow  response  to  questions  with  a  low  voice 
and  remind  one  of  the  depressive  stage  of  manic-depressive 
insanity.  This  condition  is  not  uncommon.  More  marked 
cases,  however,  present  mutism,  inactivity  and  resistance  suffi- 
cient to  warrant  characterizing  them  as  stuporous.  This  con- 
dition, however,  may  not  be  altogether  due  to  retardation  but 
may  be  the  result  of  delusions — delusional  control — to  the 
effect  they  must  not  speak,  that  it  is  wicked  to  eat,  and  the  like. 
The  mental  condition  is  one  of  intense  apprehensive  depression 
with  delusions  and  often  hallucinations.  The  retardation  in 
these  cases  by  no  means  constitutes  as  important  a  part  of  the 
clinical  picture  as  it  does  in  manic-depressive  insanity. 

A  still  further  development  of  anxiety  may  lead  to  a  condi- 
tion of  marked  and  continuous  motor  agitation  with  insomnia, 


1 66  OUTLINES    OF    PSYCHIATRY. 

refusal  of  food  and  emaciation,  with  marked  clouding  of  con- 
sciousness, hallucinations  and  disorientation. 

Confusion. — These  are  the  most  exaggerated  of  the  cases  of 
involutional  melancholia  and  lead  rapidly  to  a  condition  of 
exhaustion. 

In  these  marked  cases  of  apprehension  and  anxiety  there  is 
quite  frequently  a  considerable  amount  of  precordial  distress 
and  tachycardia  and  often  a  sense  of  oppression  over  the  chest 
w^ith  a  feeling  of  difficulty  of  breathing.  These  symptoms  are 
apt  to  appear  in  attacks,  at  which  times  the  mental  depression 
is  most  pronounced.  Although  suicidal  tendencies  are  fre- 
quent in  this  form  of  insanity,  it  is  not  necessarily  at  these 
times  that  they  are  most  apt  to  be  exaggerated. 

Farrar  distinguishes  two  forms  of  this  psychosis  which  he 
quite  clearly  defines,  viz.,  true  melancholia  or  melancholia  vera 
and  anxietas  pr'dsenilis,  while  he  describes  a  third  in  which  the 
symptoms  are  not  quite  so  well  marked  but  are  rather  of  a 
negative  character — depressio  apathetica. 

In  melancholia  vera  we  have  in  the  main  an  autopsychosis. 
The  delusions  are  auto-accusatory,  with  ideas  of  sin  but  with 
clear  consciousness ;  there  is  no  defect  of  orientation.  The  pa- 
tient believes  his  soul  is  lost,  that  he  is  to  suffer  eternal  torment 
hereafter,  and  about  these  beliefs  there  is  no  doubt,  but  on  the 
contrary  a  marked  "  subjective  certainty."  There  may  be 
some  slight  tendency  to  somatopsychic  delusions,  insight  is 
defective,  and  slight  anxiety  may  be  present. 

In  anxietas  prdsenilis  we  have,  on  the  contrary,  in  the  main 
an  allopsychosis.  There  is  a  very  marked  "  subjective  uncer- 
tainty "  which  gives  an  unreal  tinge  to  the  outer  world,  and 
out  of  which  grows  the  fear  of  things  unknown,  culminating 
in  the  marked  anxiety  which  is  characteristic  of  this  form  of 
the  psychosis.  Remorse  or  dread  of  future  are  not  elements 
in  the  depression ;  on  the  contrary,  it  is  the  great  unknown  and 
overwhelming  present  that  seems  about  to  destroy  them. 
These  cases  occur  later  in  life  than  the  former,  show  more 
evidences  of  senile  decay,  such  as  arterio-sclerosis,  and  present 


INVOLUTION    MELANCHOLIA.  167 

such  symptoms  as  verbigeration,  rhythmical  movements,  sug- 
gestibihty;  the  prognosis  is  less  favorable. 

In  deprcssio  apathetica  there  is  simply  a  let-down,  a  stop- 
ping on  the  part  of  one  who  has  been  leading  an  active  life. 
Interest  abates,  the  struggle  is  drawn  away  from  and  we  have 
a  picture  of  mild  depression  with  clear  consciousness  and  no 
disturbance  of  orientation.  There  is  some  "  subjective  uncer- 
tainty "  delusions  and  sensory  fabrications  play  little  part. 
The  symptoms  are  negative  rather  than  positive ;  the  prognosis 
is  relatively  good. 

The  danger  from  suicide  is  greater  in  this  form  of  insanity 
than  in  any  other,  and  every  case  of  melancholia  should  be 
considered  a  potential  suicide.  One  of  the  principal  reasons 
that  a  tendency  to  suicide  is  so  dangerous  a  symptom  here  is 
that  the  carrying  of  suicidal  tendencies  into  action  is  not  inter- 
fered with  by  retardation  in  the  way  in  which  it  is  in  manic- 
depressive  insanity.  In  manic-depressive  insanity  the  suicidal 
impulse  is  continuously  prevented  from  expressing  itself  in 
action  by  the  ever-present  difficulty  of  the  release  of  motor 
impulses,  while  here  no  such  difficulty  maintains,  and  the  ten- 
dency constantly  strives  to  find  expression  in  appropriate  action. 

The  delusional  content  of  consciousness  varies  widely  in 
this  disease.  Hypochondriacal  delusions  are  quite  common 
and  sometimes  we  find  nihilistic  delusions,  feeling  of  unreality, 
the  patient  claiming  that  nothing  exists,  there  are  no  people, 
no  world  and  the  like.  This  is  the  so-called  delire  de  negation 
of  the  French.  Then,  again,  we  not  infrequently  find  that 
the  delusions  take  on  very  bizarre,  absurd,  fantastic  forms, 
indicative  of  an  underlying  defect.  This  condition  may  occur 
early  in  severe  cases  or  come  later  as  evidence  of  senile  decay. 
The  same  may  be  said  of  delusions  of  grandeur,  of  great 
power,  and  the  like,  except  that  they  usually  appear  late  in 
the  course  of  the  malady  but  are  equally  evidence  of  deteriora- 
tion. There  may  be  a  strange  mixture  of  depressive  and 
grandiose  ideas,  as  with  the  patient  of  Weygandt,  who  believed 


1 68  OUTLINES    OF    PSYCHIATRY. 

she  was  going  to  be  roasted  in  a  silver  kettle.  The  deteriora- 
tion and  defect  of  judgment  is  well  shown  here. 

Weygandt  notes  the  following  list  of  delusions  that  are  found 
in  this  form  of  insanity:  (i)  Hypochondriacal  delusions;  (2) 
delusions  of  sinfulness;  (3)  delusions  of  persecution;  (4) 
delusions  of  poverty;  (5)  ideas  of  unworthiness ;  (6)  delusions 
of  explanation ;  (7)  ideas  of  insignificance;  (8)  nihilistic  ideas; 
(9)  delusions  of  possession;  (10)  ideas  of  grandeur. 

Course,  Prognosis  and  Termination. — As  compared  with 
other  curable  psychoses  this  can  hardly  be  said  to  be  of  good 
prognosis.  About  forty  per  cent,  get  well.  The  remaining 
sixty  per  cent,  terminate  in  various  ways ;  some  by  suicide, 
some  by  death  from  intercurrent  disease,  which  in  their  debili- 
tated state  is  poorly  withstood ;  some  by  death  from  gen- 
eral marasmus  or  the  development  of  tuberculosis ;  some  lapse 
into  chronicity;  and,  finally,  a  certain  few  improve  sufficiently 
to  leave  the  hospital  and  get  on  quite  well  at  home,  though 
still  somewhat  depressed.  A  certain  number  of  this  last  class 
may  get  worse  under  home  surroundings  and  have  to  be  re- 
turned to  the  hospital. 

This  latter  class  seem  to  get  on  quite  well  in  the  hospital, 
but  the  minute  they  attempt  to  take  up  the  cares  of  life,  to 
assume  the  worries  of  the  struggle  for  existence,  they  break 
down.  Perhaps  their  already  degenerated  vessels  cannot  ad- 
just themselves  to  the  increased  demands  made  upon  them  by 
a  more  active  brain. 

Unfavorable  symptoms  are  the  development  of  bizarre, 
absurd  and  grandiose  delusions  indicating  underlying  deterior- 
ation. Marked  physical  evidences  of  senility  are  also  a  poor 
omen.  A  contemporaneous  improvement  of  both  the  physical 
and  mental  conditions  is  the  most  favorable  sign. 

Pathology. — There  is  very  little  special  pathology  of  this 
disease.  An  increased  neuroglia  formation  in  the  deeper  layers 
of  the  cortex  has  been  described  and  in  this  disease  we  find 
most  often  that  condition  of  central  neuritis  described  by 
Meyer.     The  symptoms  of  this  condition  are  the  sudden  devel- 


INVOLUTION    MELANCHOLIA.  1 69 

opment  of  contractions  with  evidences  of  degeneration  in  the 
motor  tracts,  emaciation,  retraction  of  Hps  from  teeth,  low 
temperature,  semi-coma  and  death. 

Treatment. — The  foremost  consideration  in  a  great  number 
of  these  cases  is  the  prevention  of  suicide.  This  will  require 
constant  surveillance  both  night  and  day  and  in  cases  where 
the  suicidal  tendency  is  at  all  developed  it  is  rarely  justifiable 
to  attempt  this  treatment  at  home,  as  only  in  an  institution  is 
the  problem  of  taking  care  of  this  class  of  patients  appreciated 
at  its  true  value. 

Insomnia  is  a  frequent  symptom  for  which  the  usual  hyp- 
notics, paraldehyde,  sulfonal,  trional  and  chloralamid  are 
useful.  In  cases  with  high  tension  an  occasional  exhibition 
of  chloral  may  be  of  advantage.  Artificial  feeding  often  has 
to  be  resorted  to,  as  refusal  of  food  is  common.  This  means 
should  not  be  left  as  a  last  resort  but  begim  promptly  as  soon 
as  the  patient  shows  the  results  of  malnutrition,  as  this  class 
of  cases  require  supporting  treatment  much  more  than  cases 
developing  at  an  earlier  age.  If  the  apprehension  and  anxiety 
are  very  marked  and  associated  with  much  motor  agitation 
and  restlessness,  opium  may  be  tried — preferably  the  Tr.  Opii 
deod.  This  will  usually  relieve  the  mental  distress,  but  be- 
cause of  the  tendency  to  acquire  the  opium  habit  and  the 
chronicity  of  these  cases,  this  treatment  is  hardly  justifiable 
except  to  tide  over  some  exceptional  access  of  anxious  de- 
pression. 

In  such  cases  of  extreme  agitation,  hydrotherapeutic  meas- 
ures are  the  best  means  for  quieting  the  patient — the  hot 
pack  and  more  especially  the  continuous  warm  bath,  the  patient 
being  placed  in  a  tub  of  water  at  about  98°  F.  and  left  in 
several  hours,  often  all  day  each  day  and  in  some  cases  con- 
tinuously for  days  at  a  time. 

Differential  Diagnosis. — The  principal  disease  which  has 
to  be  differentiated  is  manic-depressive  insanity.  Enough  has 
already  been  said  on  this  point,  except  to  note  that  the  occur- 


I/O 


OUTLINES   OF    PSYCHIATRY. 


I 


rence  of  previous  attacks  should  be  looked  into.     They  would, 
of  course,  make  for  a  diagnosis  of  manic-depressive  insanity. 

Early  senile  insanity  is  often  hard  to  differentiate  and  in 
fact  the  two  graduate  into  one  another.  Old  cases  of  melan- 
cholia often  get  to  present  evidences  of  senile  decay.  Arterio- 
sclerosis seems  to  bridge  the  space  between  the  two  sets  of 
psychoses,  the  involutional  and  the  senile,  and  so  we  find 
symptoms  common  to  both. 


CHAPTER   XIII. 
THE   SENILE    PSYCHOSES. 

A  certain  degree  of  involution,  regression,  failure  of  both 
the  mental  and  physical  powers  is  normal  to  man  if  he  lives 
beyond  the  period  of  his  maximum  vigor.  Age,  however,  is 
not  a  matter  of  years.  Some  men  are  older  at  forty  than 
others  are  at  sixty,  and  the  dictum  that  states  that  "  a  man  is 
as  old  as  his  arteries  "  comes  very  near  to  the  truth. 

Arbitrarily  the  senium  is  said  to  begin  at  the  sixtieth  year, 
and  those  cases  which  begin  to  show  evidences  of  senile  decay 
before  this  time  are  said  to  suffer  presenile  degeneration  or 
senium  precox. 

Causes. — The  causes  of  the  senile  and  presenile  psychoses 
lie  in  the  tissue  changes  incident  to  involution.  These  changes 
begin  much  earlier  in  some  persons  than  in  others  and  in  them 
the  element  of  heredity  probably  enters  as  a  potent  factor.  A 
tendency  to  early  arterial  degeneration  certainly  occurs  in 
families.  This  tendency  may,  of  course,  be  aggravated  and 
the  changes  of  senile  degeneration  hastened  by  a  variety  of 
causes,  both  mental  and  physical,  among  which  alcoholism  is 
perhaps  the  most  prominent. 

Symptomatology. — When  senile  involution  begins  earlier 
than  the  sixtieth  year  we  have  the  condition  spoken  of  as  pre- 
senile dementia,  presenile  insanity,  or  senium  precox.  The 
symptoms  of  this  condition  differ  usually  from  those  of  simple 
senile  involution  or  even  from  the  more  common  types  of  senile 
dementia  developing  later,  and,  as  it  were,  form  a  connecting 
link  between  the  cases  of  involution  melancholia  and  the  senile 
psychoses.  The  condition  has  a  rather  long  prodromal  pe- 
riod, during  which  the  patient  complains  of  all  sorts  of  sensa- 
tions, such  as  vertigo,  general  malaise  and  various  paresthesias 
not  unlike  the  beginning  symptoms  of  involution  melancholia. 

171 


172  OUTLINES    OF    PSYCHIATRY, 

At  the  same  time  he  becomes  morose,  secliisive  and  irritable. 
From  this  condition  delusions  soon  develop  which  are  hypo- 
chondriacal and  persecutory  in  character.  These  delusions, 
however,  being  founded  upon  a  demented  basis,  partake  of 
and  show  the  element  of  defect  in  their  absurdity.  The  brain 
is  dried  up,  certain  viscera  have  been  removed,  bones  are 
broken  and  like  complaints  are  heard.  The  persecutory  delu- 
sions may  take  the  usual  form  of  poisoning  and  the  like,  but 
are  apt  to  take  on  a  sexual  type  and  wife  or  husband  believes 
his  partner  to  be  unfaithful.  These  delusions  remind  one  of 
the  similar  delusions  found  in  chronic  alcoholism,  but  they 
are  much  more  absurd  and  built  upon  the  most  inconsequential 
happenings,  often  originating  entirely  in  the  patient's  mind. 
One  not  infrequently  sees,  for  instance,  a  wife  complaining  of 
the  infidelity  and  sexual  dissipations  of  a  husband  who  is  so 
old  and  feeble  that  he  can  hardly  get  about.  These  patients 
may  be  very  irritable  at  times  and  become  very  angry  as  a 
result  of  what  they  believe  to  be  going  on,  but  they  usually 
soon  quiet  down  and  go  right  on  living  quietly  and  peacefully 
under  the  same  conditions,  making  no  effort  to  correct  them 
until  the  next  outbreak  occurs.  Their  mental  defect  is  shown 
in  these  evidences  of  lack  of  judgment  as  well  as  in  the  absurd- 
ity of  their  delusions. 

Consciousness  is  unclouded  and  the  patients  are  well  oriented. 
Emotionally  there  is  often  some  depression,  while  in  the  attacks 
of  rage  the  emotion  of  anger  occupies  the  foreground.  Hal- 
lucinations are  not  prominent  but  may  occur. 

The  more  usual  symptoms  of  senile  involution  occurring 
after  sixty  are  in  the  main  a  loss  of  memory  for  recent  events, 
due  to  lack  of  impressibility  to  the  extent  even  that  events  of 
only  an  hour  ago  are  completely  forgotten,  lack  of  ability  to 
recognize  faces,  marked  egotism,  so  that  others'  wants  and 
comforts  are  not  considered,  which  may  be  associated  with 
some  irritability  on  interference.  There  is  developed  more  and 
more  as  the  years  go  on  a  true  misoneism,  so  that  the  patient 
will  positively  not  tolerate  any  change  in  the  usual  order  of 


THE    SENILE    PSYCHOSES.  1 73 

things,  everything  must  be  done  the  same  from  day  to  day,  the 
same  seat  is  preempted,  a  particular  kind  of  food  demanded, 
and  the  Hke  with  other  comforts.  With  this  misoneism  and 
the  lack  of  memory  for  recent  events  goes  a  marked  tendency 
to  reminiscence.  The  events  of  youth  and  the  years  long  past, 
unlike  those  of  recent  occurrence,  are  vividly  recalled  and  the 
patient  thus  really  lives  in  a  world  of  former  days,  constantly 
recalling  and  reiterating  things  that  occurred  long  ago.  This 
condition  becomes  progressively  worse,  the  patient  leading  a 
vegetative  existence  almost  wholly,  no  mental  initiative,  failure 
of  judgment  and  a  progressive  loss  of  comprehension  of  the 
environment,  so  that  there  is  no  adequate  grasp  of  the  present 
at  all. 

With  this  mental  failure  goes  a  corresponding  change  on 
the  physical  side.  The  signs  of  age  are  evident  in  the  wasted 
muscles,  the  wrinkled,  inelastic  skin,  gray  hair,  the  raucous 
voice,  arcus  senilis,  senile  cutaneous  affections,  and  signs  of 
arterio-sclerosis  in  the  superficial  arteries.  In  this  connection 
it  should  be  remembered  that  the  conditions  of  the  palpable 
arteries  may  not  indicate  at  all  the  condition  of  the  cerebral 
vessels.  The  superficial  vessels  may  show  marked  arterio- 
sclerotic changes,  while  the  cerebral  vessels  are  in  relatively 
good  condition,  or,  on  the  contrary,  the  cerebral  vessels  may 
be  seriously  affected  in  a  person  whose  radials  are  compara- 
tively soft  and  whose  temporals  are  not  noticeably  tortuous. 

This  condition  of  senile  decay  may  be  said  to  be  normal, 
although  many  persons  live  to  advanced  years  without  showing 
it — it  is  the  condition  of  the  dotard.  It  is,  nevertheless,  prop- 
erly speaking,  a  true  dementia. 

If  upon  this  background  of  dementia  a  psychosis  is  developed 
its  symptoms  are  usually  shown  in  delusions,  with  perhaps 
hallucinations.  The  delusions  are  of  a  persecutory  character 
and  the  condition  may  be  spoken  of  as  paranoid.  They  are 
not,  however,  as  fixed  as  in  paranoia  and  because  of  the  demen- 
tia there  can  be  little  effort  at  systematization.  The  emotional 
attitude  varies  with  the  content  of  the  delusion  but  is  often 
marked  by  its  silly,  childish  characteristics. 


1/4  OUTLINES    OF    PSYCHIATRY. 

The  emotional  deterioration  is  well  shown  when  the  patients 
discuss  their  delusions.  One  case  tells  me  she  cannot  sleep 
nights,  for  somebody  spends  the  entire  night  shooting  her  and 
fills  her  with  bullets,  yet  while  telling  this  she  shows  no  dis- 
turbance whatever,  wears  a  slight  smile  and  talks  of  these 
events  as  if  they  were  the  most  commonplace  affairs  of  every- 
day life.  Another  old  lady  says  she  has  a  great  deal  of  money 
but  does  not  know  how  much — it  is  in  the  Court  of  Claims 
and  her  daughter  is  coming  to  take  her  home  and  then  they 
will  get  the  money.  This  is  all  told  in  the  most  matter  of  fact 
way,  repeated  as  though  it  were  a  formula  and  not  a  vital, 
living  fact  of  her  life.  This  attitude  and  emotional  poverty 
show  fully  as  well  as  the  absurdity  of  the  delusions  the  de- 
mented foundation  of  the  psychosis. 

These  patients  are  especially  apt  to  be  restless  and  suffer 
from  insomnia,  sleeping,  on  the  contrary,  much  of  the  time 
during  the  day,  even  as  they  sit  up  in  their  chairs.  Often  the 
restlessness  at  night  takes  the  form  of  wandering  about  the 
house  and  during  these  periods  they  are  apt  to  be  disoriented 
considerably  and  to  show  much  confusion.  This  tendency  to 
confusion  is,  too,  often  marked  when  the  patient  awakes  from 
a  sleep,  for  some  time  he  fails  to  apprehend  his  environment, 
does  not  know  where  he  is,  or  what  time  of  day  it  is.  It  is 
as  though  the  cerebral  circulation,  because  perhaps  of  the  dis- 
eased vessels,  took  a  very  long  time  to  readjust  itself  to  the 
waking  state. 

Aside  from  these  attacks  the  patients  may  be  quite  well 
oriented  and  there  may  be  no  clouding  of  consciousness.  On 
the  other  hand  they  may  be  disoriented,  both  as  to  time  and 
place.  This  is  often  largely  due  to  their  memory  defect,  lack 
of  attention  and  impressibility.  Such  patients  will  supply  defi- 
ciencies  in  their  memory  by  all  sorts  of  fabrications,  reminding 
one  of  the  similar  symptoms  in  paresis  and  certain  alcoholic 
cases  (Korsakow's  psychosis).  One  old  man,  although  just 
out  of  bed  and  so  feeble  he  can  hardly  stand  up,  tells  me  he 
has  been  working,  making  some  sort  of  wire  affair,  for  a  man 
on  Harrison  Street  for  the  past  seven  months. 


THE    SENILE    PSYCHOSES.  1/5 

This  form  of  senile  dementia  is  spoken  of  as  simple  senile 
deterioration. 

To  those  cases  in  which  the  symptoms  of  confusion,  which 
we  have  seen  already  occurring  in  the  form  of  senile  deteriora- 
tion just  described,  especially  connected  with  changes  in  cere- 
bral circulation,  presents  much  more  prominently,  in  which 
there  is  marked  disorientation  and  clouding  of  consciousness, 
the  designation  of  senile  confusion  is  given. 

In  these  cases  the  confusion  is  not  merely  a  transitory 
symptom,  occurring  upon  awakening,  but  is  constant.  These 
patients  do  not  know  where  they  are,  will  ask  if  dinner  is 
ready  when  perhaps  five  minutes  before  they  have  eaten  a 
hearty  meal,  forget  the  location  of  their  room,  undress  and 
go  to  bed  in  the  middle  of  the  day,  no  longer  recognizing  those 
about  them,  not  even  their  children,  and  are  difficult  to  man- 
age, headstrong,  peevish,  resistive  and  inaccessible  to  reason. 
Various  delusions  may  be  expressed,  often  hypochondriacal  in 
character,  but  quite  characteristically  absurd  in  content. 

This  variety  of  senile  dementia  often  follows  that  of  simple 
deterioration,  being  in  fact  but  a  more  pronounced  grade  of 
degeneration.  In  severe  cases  it  may  usher  in  the  mental 
changes. 

Certain  cases,  over  sixty  years  of  age,  develop  a  true  para- 
noid condition,  with  delusions  of  persecution  and  hallucina- 
tions of  hearing.  These  cases  may  not  present  marked  evi- 
dences of  senile  decay  and  consciousness  may  be  unclouded, 
orientation  complete  and  the  train  of  thought  well  maintained. 
This  condition  must  be  differentiated  from  an  alcoholic  delu- 
sional psychosis,  paranoia,  and  dementia  precox  which  Kraepe- 
lin  says  may  rarely  develop  at  advanced  age. 

Among  the  physical  symptoms  that  may  develop  in  the 
course  of  senile  deterioration  are  apoplexy,  apoplectiform  at- 
tacks and  senile  epilepsy.  True  apoplexy  may,  of  course, 
occur  and  complicate  the  picture,  while  apoplectiform  attacks 
resulting  in  transient  paralyses,  and  reminding  one  of  similar 
attacks  of  paresis  are  not  uncommon.  Epileptic  seizures  may 
take  the  form  of  either  petit  mat  or  grand  mal,  and  well  devel- 


1/6  OUTLINES    OF    PSYCHIATRY. 

oped  attacks  which  recur  with  considerable  frequency  are  not 
uncommonly  developed  in  the  senile.  Chorea,  of  the  type  of 
Huntington,  or  of  the  post-apoplectic  variety,  is  not  infre- 
quently observed  in  large  institutions  for  the  insane. 

In  an  analysis  of  two  hundred  cases  of  senile  dementia  Dana 
gives  the  following  list  of  symptoms  which  he  found  and 
which  I  reproduce  in  the  order  of  their  relative  frequency : 
Wandering  street ;  hallucinations  prominent ;  violence ;  vertigo ; 
persecutory  ideas,  other  than  poisoning,  conspiracy,  etc. ;  exal- 
tation; night  prowling;  apoplectiform  strokes;  headache;  sui- 
cidal attempts ;  suspicion  of  conspiracy ;  suspicion  of  poisoning ; 
violence  at  night;  epileptiform  attacks;  delusions  of  marital 
infidelity ;  setting  fire  to  things ;  echolalia ;  chorea. 

In  addition  to  the  types  of  cases  already  discussed  a  senile 
delirium  has  been  described.  This  condition  is  characterized 
by  varied  and  fleeting  delusions,  multiform  hallucinations, 
clouding  of  consciousness,  great  incoherence  and  marked  motor 
restlessness,  often  an  occupation  delirium.  This  may  usher 
in  a  case  that  has  been  up  to  that  time  following  a  normal 
course,  or  it  may  occur  as  an  episode  in  any  case  of  senile 
psychosis.  As  in  the  condition  of  acute  delirious  mania,  so 
here  I  think  it  should  usually  be  attributed  to  some  bodily 
cause, — pneumonia,  nephritis,  cystitis.  It  may  clear  up  but  is 
frequently  fatal,  and  in  these  cases  it  is  not  improbable  that  the 
delirium  is  a  manifestation  of  a  terminal  infection. 

Course  and  Prognosis. — The  course  of  senile  dementia  is 
progressive  until  death.  The  patients  finally  become  com- 
pletely demented,  so  that  they  are  wholly  disoriented,  confused, 
know  no  one  around  them,  in  fact  may  not  even  know  their 
own  name. 

It  is  quite  possible  to  have  attacks  of  other  psychoses  at  this 
time  of  life,  particularly  stages  of  manic-depressive  insanity. 
The  prognosis  of  the  psychosis  is  not  changed  materially  by 
the  senium  except  of  course  that  exhaustion  is  more  apt  to 
occur  and  of  course  terminate  the  case.  The  underlying  de- 
mentia continues  the  same  or  perhaps  is  somewhat  worse  after 


THE   SENILE   PSYCHOSES.  I// 

the  attack  passes  off.  The  senile  deterioration  being  due  to 
actual  tissue  changes,  remains  stationary  or  gets  progressively 
worse,  while  the  psychosis  engrafted  upon  it  may  or  may  not 
be  recovered  from. 

Diagnosis. — Paranoia  must  be  differentiated  by  the  history. 
Many  cases  of  paranoia  develop  senile  deterioration  but  the 
history  would  show  an  early  development  of  symptoms. 

Dementia  precox,  if  in  fact  it  does  occur  so  late  in  life,  would 
have  to  be  diagnosed  by  the  disturbances  of  motility,  the  cata- 
tonic symptoms. 

The  cases  with  well-marked  arterio-sclerosis  and  multiple 
areas  of  softening  present  a  picture  closely  resembling  paresis. 
A  careful  study  of  the  reflexes,  both  pupillary  and  tendinous, 
a  consideration  of  the  speech  defect  which  is  more  truly  aphasic, 
and  the  age  of  the  patient  with  evidences  of  arterio-sclerosis, 
but  without  evidences  of  syphilis,  will  usually  serve  to  make 
the  distinction. 

There  are  certain  borderland  cases  presenting  emotional 
depression  that  are  difficult  to  distinguish  from  involution  mel- 
ancholia. The  presence  of  defect  is  the  criterion  to  judge  by, 
though  these  two  conditions  do  undoubtedly  graduate  into  one 
another  and  as  already  stated  melancholiacs  after  a  prolonged 
duration  may  develop  senile  deterioration. 

Pathology. — Grossly  the  brain  shows  signs  of  atrophy  and 
decreased  weight.  The  dura  may  be  adherent  to  the  calvarium 
and  may  present  internal  hemorrhagic  pachymeningitis.  The 
pacchionian  granulations  are  increased  in  size.  The  lepto- 
meninges  are  thickened,  especially  the  pia,  which  is  turbid 
from  lymph  exudate.  The  sub-arachnoid  space  is  filled  with 
fluid,  which  takes  the  place  of  the  atrophied  convolutions — 
hydrocephalus  ex  vacuo.  The  convolutions  are  shrunken  and 
the  fissures  between  them  widened.  The  blood  vessels  show 
the  changes  of  arterio-sclerosis,  there  may  be  thrombosis,  or 
the  lumen  of  some  of  the  smaller  ones  may  be  very  greatly 
reduced,  thus  impairing  the  nutrition  of  the  area,  to  which  they 
are  distributed.  Miliary  aneurisms  may  occur  and  hemor- 
13 


178  OUTLINES    OF    PSYCHIATRY. 

rhage  from  rupture  of  them  is  not  infrequent.  Multiple  areas 
of  softening  may  be  present  from  these  various  sources,  more 
especially  in  the  cortex. 

Microscopically  the  cells  show  degenerative  changes,  espe- 
cially an  increase  in  yellow  pigment  amounting  to  a  pigmen- 
tary degeneration.  There  is  also  a  disappearance  of  fibers, 
especially  the  tangential.  These  having  association  functions 
their  disappearance  accounts  in  a  measure  for  the  dementia. 
The  neuroglia  is  increased  and  sclerosis  of  the  cortex  is  com- 
monly found. 

Aside  from  these  changes  other  organs  are  usually  found 
affected,  particularly  the  heart  and  kidneys,  the  former  show- 
ing degenerative  changes  in  the  myocardium,  the  latter  evi- 
dences of  chronic  nephritis. 

Treatment. — The  mild  cases,  especially  those  that  maintain 
their  orientation  fairly  well,  can  be  cared  for  at  home.  Those 
with  marked  confusion,  especially  with  a  tendency  to  wander- 
ing, need  an  attendant  to  be  with  them.  There  is  danger  of 
their  becoming  lost  and  coming  to  grief,  or  if  they  wander 
about  the  house  at  night  they  are  apt  to  meet  with  some  acci- 
dent, more  often  to  fall  down  stairs  and  sustain  fractures. 
Patients  who  are  very  resistive,  present  surgical  troubles,  are 
filthy  in  habits,  or  show  a  tendency  to  commit  sexual  crimes, 
should  be  cared  for  in  an  institution. 

As  regards  the  more  special  treatment,  little  is  to  be  said. 
Hygienic  surroundings,  a  simple  diet,  looking  after  the  emunc- 
tories,  and  if  insomnia  is  present  the  occasional  exhibition  of 
a  hypnotic  constitutes  about  all  there  is  to  be  done.  In  this 
class  of  cases,  more  perhaps  than  in  any  other,  is  the  use  of 
alcohol  as  a  hypnotic  indicated.  A  little  whiskey  and  hot 
water,  or  a  glass  of  beer  or  ale  acts  very  nicely.  It  should  be 
given,  however,  strictly  under  medical  authority  and  super- 
vision, as  these  patients  are  apt  to  be  susceptible  to  its  influ- 
ences. In  the  earlier  stages  of  the  disease  potassium  iodide 
is  the  drug  par  excellence  for  its  general  alterative  properties 
and  its  effect  on  the  arterial  tension. 


the  senile  psychoses.  179 

The  Epochal  Insanities  in  General. 

Our  description  of  the  epochal  insanities,  i.  c,  the  insanities 
of  adolescence,  involution  and  the  senium  has  shown  that  in 
general  the  insanities  that  are  characteristic  of  these  periods 
of  life  tend  to  dementia.  Recalling  our  previous  remarks 
along  these  lines,  that  persons  with  deficient  developmental 
force  tend  to  break  down  at  that  period  of  life  to  which  their 
developmental  forces  have  been  able  to  carry  them,  it  seems 
that  it  would  be  fair  to  assume,  and  Bolton  in  a  recent  excel- 
lent study  has  in  fact  attempted  to  prove,  that  dementia  is  the 
expression  of  ''neuronic  degeneration/'  he  believes  in  every 
instance  "  following  insufficient  durability."  As  a  further  re- 
sult of  his  studies  he  describes  the  condition  of  amentia  as 
occupying  a  mid-position  between  these  dementias  on  the  one 
hand  and  normal  individuals  on  the  other  hand,  and  states  the 
underlying  condition  to  be  "deficient  neuronic  development." 

A  consideration  of  the  dementing  psychoses,  especially  those 
that  occur  at  the  critical  periods  of  life,  adolescence,  the  cli- 
macteric and  the  senium — from  these  general  view-points, 
namely,  as  being  due  to  a  failure  in  the  developmental  forces 
and  "  deficient  neuronic  development "  and  resulting  in  "  neu- 
ronic degeneration,"  will  make  their  relations  to  one  another 
much  more  clear.  We  can  correlate  the  confusion,  the  emo- 
tional deterioration  and  memory  defects  of  dementia  precox 
and  senile  dementia  and  can  understand  that  the  peculiar  dis- 
turbances of  motility  in  catatonia  may  be  found  in  certain  cases 
of  senile  dementia,  or,  on  the  other  hand,  be  represented  in 
the  resistance  (negativism)  of  involution  melancholia.  We 
can  understand  why  our  cases  of  involution  melancholia  do 
not  get  well  and  how  it  is  that  we  frequently  find  signs  of 
arterial  degeneration  and  pre-senility  in  cases  of  adolescent 
insanity.  We  can  also  understand  why  in  certain  toxic- 
exhaustive  cases  developing  in  predisposed  individuals  we 
might  get  symptoms  of  this  adolescent-climacteric-senile  group, 
for  example,  negativism,  catalepsy,  stupor,  etc. 


l80  OUTLINES    OF    PSYCHIATRY. 

In  the  past  it  has  been  common  to  describe  certain  other 
psychoses  occurring  at  physiological  epochs  and  give  them  the 
name  of  the  epoch  during  which  they  occurred.  Thus  we  find 
the  group  of  puerperal  insanities,  especially  puerperal  mania, 
and  the  lactational  insanities. 

The  causes  operating  at  these  periods  to  produce  mental  dis- 
turbances are  in  the  main  two — infection  and  exhaustion.  A 
large  number  of  these  psychoses  therefore  naturally  group 
themselves  under  the  infection-exhaustion  types  to  be  described 
in  the  next  chapter.  It  will  be  understood,  however,  that  the 
strains  incident  to  pregnancy,  parturition,  the  puerperium  and 
lactation  may  produce  outbreaks  of  other  psychoses,  particu- 
larly dementia  precox. 

We  see,  therefore,  that  there  is  no  such  thing,  for  example, 
as  puerperal  insanity,  strictly  speaking.  Insanity  frequently 
occurs  during  the  puerperium  but  must  be  classified  in  accord- 
ance with  the  symptoms  it  presents  rather  than  the  time  at 
which  it  occurs. 


I 


CHAPTER   XIV. 
THE  INFECTION-EXHAUSTION  PSYCHOSES. 

The  infection  and  exhaustion  psychoses  are  classified  together 
in  this  chapter  partly  because  of  the  closely  similar  picture  their 
respective  psychoses  present  and  partly  because  of  the  fact  that 
the  two  conditions  are  so  closely  and  so  frequently  found  asso- 
ciated clinically.  It  would  be  difficult,  for  example,  to  dis- 
criminate the  two  factors  in  a  post-mortem  case  where  there 
had  been  infection  following  a  prolonged  and  difficult  labor 
with  considerable  hemorrhage.  Then,  again,  it  is  probable 
that  the  immediate  causes  are  not  altogether  dissimilar  in  the 
two  conditions,  as  it  seems  to  be  fairly  well  demonstrated  that 
the  symptoms  of  fatigue  are  due  to  a  toxemia,  the  result  of  the 
development  of  poisonous  substances  in  the  body  from  the 
chemical  breaking  down  of  tissue. 

In  this  chapter  it  will  be  necessary  to  frequently  use  the 
terms  confusion  and  delirium.  By  confusion  is  meant  a  state 
of  disorientation  in  all  the  three  spheres — temporal,  spatial  and 
personal.  The  confusion  and  consequent  disorientation  may 
be  of  any  degree.  By  delirium  is  meant  a  confused  and 
clouded  state  of  consciousness  associated  with  and  symptomatic 
of  fever.  The  two  terms  are  not  clearly  differentiated,  as  we 
speak  of  pre-febrile  delirium. 

In  previous  chapters  I  have  emphasized  the  fact  that  the 
condition  of  permanent  mental  impairment — dementia — modi- 
fied the  symptoms  of  a  psychosis,  so,  for  example,  if  there  was 
a  delusional  state,  the  delusions  tended  more  to  take  on  strange, 
bizarre,  fantastic  characters  because  of  the  lack  of  judgment 
and  of  the  critical  faculty.  What  has  been  said  in  this  respect 
of  the  permanent  mental  impairment  of  dementia  may  be  as 
well  said  of  the  more  acute,  transitory  states  of  mental  impair- 


I<5  2  OUTLINES   OF    PSYCHIATRY. 

ment — confusion  and  delirium.  In  these  conditions  with  dis- 
orientation and  clouding  of  consciousness  the  judgment  is  also 
greatly  impaired  and  the  critical  faculty  practically  in  abeyance. 
As  a  result,  we  see  here  also  the  most  fantastic  delusions.  The 
delusions,  however,  are  less  apt  to  have  any  fixity  because  of 
the  multiplicity  and  changeableness  of  the  symptoms  in  the 
psychosensory  field  on  which  they  are  largely  dependent. 

Pre-Febrile,  Febrile  and  Post-Febrile  Psychoses. 

Speaking  generally  fever  and  infection  may  be  said  to  be 
measures  of  the  mental  stability  of  an  individual.  While  some 
persons  will  remain  mentally  clear  with  a  fever  of  io6°,  others 
will  become  delirious  with  only  a  slight  rise  in  temperature. 
Some  persons  will  go  through  an  attack  of  typhoid,  for  in- 
stance, with  little  or  no  delirium,  while  in  other  cases  delirium 
is  an  early  symptom  and  continues  throughout  the  course  of 
the  disease.  The  lack  of  resistance  is  sometimes  very  marked 
indeed.  I  recall  a  young  man  who  developed  marked  symp- 
toms as  a  result  of  a  very  slight  infection  of  a  finger.  There 
was  only  a  drop  or  two  of  pus,  no  ascending  lymphangitis  and 
only  about  a  degree  of  temperature,  yet  his  resistance  was  so 
poor  that  he  was  temporarily  deranged.  In  general,  these 
cases  are  of  poorer  prognosis  than  the  more  resistive.  It  is 
generally  considered,  for  instance,  that  the  early  development 
of  delirium  in  typhoid  is  a  bad  sign,  indicating  that  the  ner- 
vous system  is  seriously  involved  and  that  the  case  is  going 
to  be  a  severe  one. 

Infection  Delirium. — Under  this  head  is  included  the  men- 
tal disturbances  which  develop  early  in  the  infectious  diseases, 
either  before  the  fever  appears  at  all  or  else  when  it  is  still  so 
low  that  the  mental  disturbance  cannot  be  attributed  to  it  and 
therefore  must  be  due  solely  to  the  infectious  agent — (initial 
delirium).  This  condition  is  found  associated  with  typhoid, 
typhus,  smallpox,  malaria  and  hydrophobia.  It  usually  takes 
the  form  of  an  acute  confusion,  but  there  may  be  delusions  of 
a  consistently  disagreeable  character,   generally   persecutory 


INFECTION-EXHAUSTION    PSYCHOSES.  1 83 

The  condition  in  hydrophobia  is  rather  one  of  change  of  char- 
acter, irritability,  restlessness,  usually  depression,  verging  into 
a  delirium  with  confusion,  hallucinations  and  excitement  as  the 
disease  progresses.  In  those  cases  especially  in  which  the 
delirium  is  a  very  early  symptom,  occurring  before  the  fever, 
the  diagnosis  is  very  difficult  and  may  be  quite  impossible  until 
the  infectious  disease  is  frankly  established. 

Febrile  Delirium. — A  condition  of  acute  confusion  of  vari- 
able intensity,  usually  following  in  its  degrees  the  febrile  move- 
ment. The  milder  cases  usually  exhibit  symptoms  only  as 
night  approaches,  at  which  time  they  begin  to  mistake  objects 
in  the  room,  become  disoriented,  mildly  confused  and  restless. 
More  severe  cases  present  marked  clouding  of  consciousness, 
disorientation,  multiform  and  often  terrifying  hallucinations 
and  dreamy  delusions.  Objects  in  the  room  are  mistaken,  a 
spot  on  the  floor  is  blood,  the  bed  is  on  fire,  visions  are  seen 
on  the  walls  and  ceilings.  In  this  state  there  is  considerable 
noisy  excitement.  This  condition  may  become  more  aggra- 
vated, the  excitement  more  marked,  leading  to  great  agitation, 
restlessness  and  finally  purposeless  movements,  the  expressions 
become  very  incoherent,  a  low  muttering  delirium  develops 
with  subsultus  tendinum  and  carphologia. 

The  onset  and  severity  of  the  delirium  is,  to  an  extent,  a 
measure  of  the  mental  stability  of  the  patient.  Delirium  de- 
velops much  more  readily  in  the  unstable  and  those  predisposed 
to  the  development  of  psychotic  symptoms. 

Post-Febrile  Psychoses. — These  conditions  either  develop 
as  a  result  of  the  delirium  of  the  febrile  state,  continuing  after 
the  fever  has  subsided,  or  may  take  their  origin  from  the  first 
during  the  post-febrile  period.  In  the  latter  case  the  disease 
is  essentially  an  exhaustion  psychosis. 

The  mental  state  is  one  of  confusion,  with  multiform  hallu- 
cinations— the  patient  sees  strange  faces  peering  at  him  from 
the  pictures  on  the  wall,  he  can  see  through  the  walls  into  the 
next  house,  the  pictures  turn  about  and  change  places — there  is 
a  marked  disorientation  and  delusions  usually  of  a  persecutory 


1 84  OUTLINES    OF    PSYCHIATRY. 

nature — poison  is  administered  in  the  medicine.  This  condi- 
tion may  become  more  severe,  the  dehrium  more  active,  the 
utterances  very  incoherent  and  finally  a  stuporous  state  de- 
velops with  a  tendency  to  catalepsy. 

The  exhaustion  in  most  of  these  cases  may  be  profound  and 
terminate  fatally ;  a  certain  few  go  on  to  the  development  of  a 
chronic  delusional  state.  Improvement  in  the  general  physical 
state  is  accompanied  by  mental  improvement. 

Exhaustion  Psychoses. 

These  conditions  develop  after  severe  exhaustion  from  any 
cause — loss  of  blood,  parturition,  prolonged  anxiety  and  worry, 
severe  mental  shock,  prolonged  convalescence  from  the  acute 
fevers,  such  as  typhoid,  pneumonia,  the  exanthemata,  etc. 

Collapse  Delirium. — This  is  the  dcliriinn  grave  or  the  acute 
delirious  mania  of  the  older  authors. 

The  disease  may  present  a  prodromal  period  of  restless  irri- 
tability and  insomnia,  after  which  a  condition  of  confusion 
develops  which  may  be  very  mild,  constituting  only  a  slight 
degree  of  perplexity  or  more  usually  manifesting  hallucina- 
tions, clouding  of  consciousness,  disorientation  and  dreamy 
delusions.  Psychomotor  excitement  is  common,  the  patient 
being  very  active  and  inclined  to  acts  of  violence  and  destruct- 
iveness. 

The  degree  of  excitement  in  these  cases  may  become  very 
great  indeed,  in  fact  exceeding  anything  we  see  in  the  other 
psychoses.  When  this  extreme  form  was  the  only  one  rec- 
ognized the  disease  was  supposed  to  have  a  uniformly  fatal 
termination. 

In  these  severe  cases  the  incoherence  becomes  absolute, 
disorientation  complete,  clouding  of  consciousness  profound. 
Temperature  usually  develops  and  may  be  very  high — 106". 
Gastro-intestinal  symptoms  are  common,  there  is  almost  com- 
plete anorexia,  coated  tongue,  a  frothy,  offensive  diarrhea,  a 
high  grade  of  indicanuria  and  great  emaciation,  a  severe  grade 
of  exhaustion,  with  typhoid  symptoms  followed  in  a  large  pro- 
portion of  cases  by  coma  and  death. 


INFECTION-EXHAUSTION    PSYCHOSES.  185 

Stupor  with  catalepsy  may  constitute  an  episode  or  be  suffi- 
ciently in  evidence  to  give  its  character  to  the  attack. 

Though  the  severe  cases  almost  all  die,  the  milder  cases 
usually  make  good  recoveries.  Of  all  cases,  perhaps  fifty  per 
cent,  are  fatal. 

As  was  indicated  in  the  chapter  on  manic-depressive  insanity 
some  of  these  cases  may  be  extreme  forms  of  other  psychoses, 
while  many  of  them  are  found  to  present  at  autopsy  some  acute 
disease,  such  as  pneumonia,  nephritis,  that  accounts  for  the 
symptoms.  It  is,  of  course,  readily  seen  how  difficult  the  diag- 
nosis of  conditions  dependent  on  careful  physical  examination 
must  be  in  these  wildly  excited  cases. 

These  cases  have  a  short  duration,  ending  in  recovery  or 
death  in  a  few  days  or  at  most  a  few  weeks. 

Acute  Hallucinatory  Confusion. — This  psychosis  is  less 
acute  than  the  former  but  of  the  same  general  nature,  and  may 
be  described  as  an  acute  primary  insanity,  characterized  by 
clouding  of  consciousness,  confusion,  multiform  and  usually 
fleeting  hallucinations  in  the  various  sensory  areas,  changeable 
delusions,  the  emotional  attitude  being  variable  and  in  general 
corresponding  to  the  content  of  the  delusions.  It  is  generally 
of  considerable  duration,  often  many  months.  The  course  is 
somewhat  irregular  and  not  infrequently  interrupted  by  lucid 
intervals  which  may  be  of  only  a  few  minutes  duration  or  may 
last  a  day  or  two.  This  is  important  to  know,  so  that  a  lucid 
interval  will  not  be  definitely  stated  to  be  the  beginning  of  per- 
manent recovery. 

As  in  the  preceding  form,  stuporous  states  may  intervene 
and  for  a  considerable  time  dominate  the  picture. 

Diagnosis  of  the  Infection — Exhaustion  Psychoses. — 
The  diagnosis  is  to  be  made  in  general  from  the  association  of 
acute  confusion,  multiform  hallucinations,  changeable  delusions, 
disorientation,  clouding  of  consciousness  and  variable  emotional 
reactions,  with  specific  infection,  or  coupled  with  the  physical 
signs  of  exhaustion,  great  emaciation  and  fever.  It  must  not 
be  forgotten  that  certain  other  insanities,  particularly  dementia 


1 86  OUTLINES    OF    PSYCHIATRY. 

precox  and  manic-depressive  insanity,  may  originate  under  the 
same  conditions  which  lead  to  the  development  of  the  infec- 
tion— exhaustion  psychoses,  and  further,  that  aside  from  the 
conditions  of  confusion  described  (primary  confusion) ,  states 
of  infection  and  exhaustion  may  complicate  any  psychosis, 
producing  a  confusion  engrafted  on  the  original  mental  dis- 
order (secondary  confusion) .  Recurring  attacks  of  confusion 
should  cause  us  to  consider  the  possibility  of  some  other 
psychosis. 

Special  care  should  be  exercised  in  excluding  delirium 
tremens  and  epileptic  dream  states.  The  characteristic  hallu- 
cinations of  delirium  tremens  are  not  present,  while  the  anam- 
nesis or  scars  about  the  head  and  face  will  indicate  the  presence 
of  epilepsy. 

Catatonic  excitement  is  not  accompanied  by  the  signs  of 
such  great  exhaustion  or  by  such  marked  emaciation. 

Treatment. — The  treatment  must,  of  course,  where  a  spe- 
cific disease,  such  as  typhoid  is  present,  be  in  the  main  the 
treatment  of  the  underlying  disease.  Otherwise  the  treatment 
is  supporting  and  sedative. 

For  the  excitement  the  continuous  bath  or  wet  pack  with 
the  occasional  exhibition  of  a  hypnotic. 

Forced  feeding  should  be  begun  as  soon  as  the  patient  begins 
to  refuse  food,  as  these  cases  have  no  strength  to  spare  for 
the  experiment  of  waiting  to  see  whether  they  will  eat. 

The  gastric  disturbance  in  many  of  these  cases  is  so  marked 
that  if  the  usual  feeding  is  given  it  will  be  promptly  vomited. 
Such  cases  should  be  fed  small  amounts  often. 

In  the  extreme  exhaustion  of  the  later  stages  hypodermo- 
clysis  may  be  used  with  beneficial  results. 


CHAPTER   XV. 
THE  TOXIC  PSYCHOSES. 

Toxins  may  be  classified  on  the  basis  of  whether  they  origi- 
nate within  the  body — endogenous — or  are  introduced  from 
without — exogenous.  The  former  are  often  spoken  of  as 
auto-toxins  and  the  conditions  resulting  from  them  as  auto- 
toxic  states  or  as  auto-intoxication. 

Auto-toxic  Psychoses. 

Uremia. — The  auto-intoxication  which  develops  as  a  result 
of  renal  disease  produces  mental  symptoms  of  an  acute  confu- 
sion with  changeable  delusions,  hallucinations,  clouding  of 
consciousness,  restlessness.  The  character  of  the  delusions 
may  be  more  or  less  consistently  grandiose,  giving  rise  to  an 
expansive  form,  or  depressive,  giving  rise  to  the  depressive 
form.  In  sub-acute  cases  a  condition  of  suspicion,  anxiety, 
with  systematized  delusions  of  persecution,  sometimes  develop. 

Diagnosis. — The  diagnosis  is  to  be  made  from  the  associa- 
tion of  an  acute  confusion  with  the  uremic  state.  The  sub- 
acute cases  may  mislead  as  they  have  the  outward  semblance 
of  chronic  insanity.  The  history  will,  however,  show  an  acute 
onset  and  the  physical  examination  will  disclose  evidences  of 
renal  disease. 

Diabetes. — The  mental  disorder  associated  with  diabetes  is 
usually  of  a  mild  chronic  type.  It  is  invariably  a  depression, 
with  melancholic  ideas  of  sin,  ruin  and  usually  also  hypochon- 
driacal ideas,  especially  with  reference  to  the  excretion  of 
sugar.  There  is  liable  to  be  marked  somnolence  with  some 
confusion  and  disorientation  in  the  semi-somnolent  state.  Per- 
secutory delusions  are  quite  frequently  developed,  ideas  of 
poisoning  and  the  like. 

187 


1 88  OUTLINES    OF    PSYCHIATRY. 

Diagnosis. — The  persecutory  type  must  be  differentiated 
from  the  chronic  psychoses.  Otherwise  the  diagnosis  is  made 
by  the  association  of  the  mental  symptoms  with  glycosuria. 

Gastro-Intestinal. — Certain  cases  of  acute  confusion  de- 
velop, associated  with  a  profuse,  offensive  diarrhea,  a  high 
grade  of  indicanuria,  vomiting,  low  fever  and  perhaps  mild 
albumenuria.  Some  of  these  cases  go  on  to  acute  delirium, 
with  high  fever,  typhoid  state,  profound  exhaustion,  coma  and 
death. 

Thyroigenous  Psychoses. 

The  thyroigenous  psychoses  may  be  divided  in  two  classes : 
Those  due  to  defect  of  secretions — myxoedema  and  cretinism — 
and  those  due  to  hypersecretion — exophthalmic  goitre. 

Myxoedema. — Associated  with  the  physical  symptoms  of 
myxoedema  is  a  mental  state  of  stupidity,  indifference  and 
apathy,  deepening  into  dementia.  There  is  gradual  failure  of 
memory,  lack  of  power  of  voluntary  attention,  slow  association 
of  ideas  and  difficulty  of  apprehension.  Sometimes  a  moderate 
degree  of  confusion  with  excitement  develops. 

Cretinism. — Associated  with  the  physical  signs  of  cretinism 
is  a  mental  state,  due  to  lack  of  development,  which  may  range 
all  the  way  from  the  profound  degradation  of  idiocy  to  mild 
grades  of  imbecility. 

Exophthalmic  Goitre. — This  disease  is  not  infrequently 
associated  with  hallucinations  of  hearing,  voices  being  heard 
saying  disagreeable  things  to  the  patient.  With  these  halluci- 
nations occur  anxious  and  agitated  states.  The  prognosis  in 
these  cases  is  bad.     Many  of  them  die. 

Then  severe  cases  of  acute  thyroidism  are  seen  occasionally, 
following  operations  upon  the  gland  and  may  be  due  to  the 
expression  of  its  secretions  by  handling  it  and  subsequent 
absorption. 


the  toxic  psychoses.  1 89 

Toxic  Psychoses. 

Alcoholism. 

The  role  that  alcohol  plays  in  the  production  of  psychoses, 
while  admittedly  an  important  one,  is  not  at  all  well  under- 
stood. Recent  statistics,  conservatively  interpreted,  would  in- 
dicate that  about  twelve  per  cent,  of  the  cases  of  insane  confined 
in  public  institutions  in  the  United  States  are  insane  because 
of  its  influence,  direct  or  indirect.  When,  however,  the  multi- 
tudinous ways  in  which  alcohol  may  enter  as  a  factor  in  the 
production  of  mental  disease  and  the  far-reaching  effects  it 
produces  are  considered  it  is  readily  seen  that  no  statistical 
study  can  begin  to  fathom  the  problem. 

While  the  psychoses  considered  under  this  heading  seem  to 
be  closely  associated  with  alcohol  and  in  the  main  present 
fairly  constant  and  characteristic  pictures,  it  must  not  be  for- 
gotten that  alcohol  may  enter  as  an  etiological  factor  in  the 
production  of  symptoms  ordinarily  considered  to  be  quite  dis- 
tinct from  the  alcoholic  psychoses  properly  so-called,  such  as 
manic-depressive  insanity,  while  it  is  considered  by  some  to  be 
a  very  important  causative  agent  in  paresis. 

When  attacks,  for  instance,  of  manic-depressive  insanity  are 
brought  about  by  alcoholic  indulgence  it  is  probable  that  they 
are  considerably  modified  as  a  result  and  present  a  somewhat 
atypical  picture. 

That  the  psychoses  produced  as  the  result  of  abuse  of  alcohol 
are  dependent,  in  the  last  analysis,  upon  something  besides  the 
alcohol,  namely,  upon  some  peculiarity  of  makeup  of  the  indi- 
vidual is  well  shown  by  the  fact  that  while  a  history  of  abuse 
of  alcohol  is  frequent  in  cases  admitted  to  hospitals  for  the 
insane,  it  is  very  rare  to  find  at  autopsy  what  in  general  hos- 
pitals is  considered  so  typical  of  alcoholism,  namely,  cirrhosis 
of  the  liver.  This  means  that  the  locus  minoris  resistentics 
in  these  cases  was  the  brain  and  that  mental  disease  supervened 
before  the  liver  was  involved. 

Drunkenness. — Alcohol,  like  fever,  may  be  said  to  be  a 


190  OUTLINES    OF    PSYCHIATRY. 

measure  of  cerebral  resistance,  the  unstable,  predisposed  in- 
dividual becoming  intoxicated  much  more  readily  than  the 
normal. 

The  phenomena  of  drunkenness  are,  from  the  first,  phe- 
nomena of  paral3^sis.  In  the  early  stages  it  is  only  the  higher 
psychic  functions,  which  are  largely  inhibitive,  that  are  affected, 
so  we  get  apparent  stimulation  in  the  excitement  produced  with 
flight  of  ideas,  pressure  of  activity,  loss  of  the  sense  of  pro- 
priety, degradation  of  the  moral  tone  and  loss  of  power  of 
voluntary  attention.  The  lower  centers  then  become  paralyzed 
and  then  appears  muscular  incoordination,  manifesting  itself 
first  in  the  hands  and  facial  muscles  and  the  muscles  con- 
trolling articulation,  the  speech  becomes  thick  and  the  gait 
unsteady.  Sensory  disturbances  appear,  such  as  diplopia,  tin- 
nitus aurium,  and  the  senses  of  touch  and  pain  are  blunted. 
If  the  paralyzing  action  of  the  alcohol  continues  coma  results, 
which  may  be  fatal.  The  mood  during  intoxication  may  be 
a  pleasant  one,  and  frequently  is  one  of  boisterous  exaltation, 
constituting  the  exalted  type;  on  the  other  hand,  a  sad,  depres- 
sive, lachrymose  mood  may  prevail  constituting  the  depressed 
type. 

Pathological  Drunkenness. — Among  certain  predisposed 
individuals  alcohol  produces  unusual  and  much  more  severe 
symptoms.  In  this  condition  we  may  find  hallucinations  and 
delusions  dominating  the  field  of  consciousness,  the  delusions 
being  usually  of  a  persecutory  character.  In  other  cases  the 
excitement  may  issue  in  a  wild  maniacal  frenzy  or  the  depres- 
sion may  be  so  profound  as  to  result  in  attempts  at  suicide. 
In  some  persons  the  paralyzing  effects  of  alcohol  are  unusually 
pronounced  and  coma  appears  early  on  the  scene.  Those  who 
have  latent  hysterical  tendencies  may  have  hysterical  attacks 
during  intoxication,  while  alcohol  frequently  produces  convul- 
sions in  epileptics.  Aside  from  this  latter  action,  however,  the 
convulsive  properties  of  alcohol  alone  are  capable  of  producing 
convulsions  in  persons  who  have  long  indulged  and  are  pro- 
foundly degenerated. 


THE    TOXIC    PSYCHOSES.  I9I 

In  these  cases  of  pathological  drunkenness  in  which  the  reac- 
tion to  alcohol  is  so  pronounced  it  is  quite  common  to  find 
amnesia  for  periods  of  profound  intoxication. 

Delirium  Tremens. — This  disorder  usually  occurs  as  the 
result  of  a  prolonged  drunken  debauch  of  a  chronic  alcoholic, 
during  which  the  patient  has  had  insufficient  food  and  rest. 
According  to  some  authors,  it  may  result  directly  from  the 
withdrawal  of  alcohol.  It  may,  however,  appear  as  the  result 
of  a  single  excess  or  in  the  moderate  but  continuous  drinker, 
following  a  traumatism  or  the  initial  symptoms  of  an  acute 
illness.  The  disease  may  appear  suddenly,  but  there  is  gener- 
ally a  prodromal  period  during  which  the  patient  is  nervous, 
with  coated  tongue,  suffering  from  anorexia,  restlessness, 
tremulousness,  disturbed  sleep  and  insomnia.  This  condition 
rapidly  advances  with  the  onset  of  the  attack,  the  characteristic 
symptoms  of  which  are  rapidly  developed.  They  are  tremor, 
delirium  and  albuminuria. 

The  tremor  involves  more  particularly  the  small  muscles  of 
the  hand,  face  and  tongue,  but  may  also  affect  the  entire  mus- 
culature. It  is  increased  by  muscular  tension,  such  as  forcibly 
spreading  the  fingers  apart. 

The  delirium  is  an  acute  hallucinatory  confusion. 

Disorientation  is  often  quite  complete,  the  patient,  although 
perhaps  fastened  in  bed,  believing  himself  in  his  office  or  home, 
surrounded  by  familiar  faces.  The  predominating  hallucina- 
tions are  visual  and  characteristically  take  on  the  form  of 
animals.  The  patient  sees  all  sorts  of  horrible  creatures, 
snakes,  rats,  mice,  alligators,  etc.,  which  are  uniformly  in 
motion.  Surrounded  by  the  loathsome  creatures  and  by  hor- 
ribly grimacing  faces,  terrified  by  screams  and  shrieks  (audi- 
tory hallucinations),  he  presents  a  picture  of  abject  terror.  In 
addition  to  these  symptoms,  the  patient  may  complain  that 
insects  or  worms  are  crawling  under  his  skin  (paresthesia) 
and  mistake  spots  upon  the  bed  or  walls  for  bugs,  mice,  etc. 
(illusions).  At  the  height  of  his  excitement  the  patient  is  in 
constant  motion,  picking  insects  from  his  nightdress,  repelling 


192  OUTLINES    OF    PSYCHIATRY. 

the  approach  of  terrible  animals ;  in  the  extreme  frenzy  of  his 
fright,  he  may  make  murderous  assaults  on  those  about  him, 
believing  them  to  be  his  enemies,  or  perhaps  attempt  his  own 
life  to  escape  from  his  horrible  surroundings.  During  all  this 
time  the  patient  is  constantly  talking,  shrieking  in  fear  at  times, 
at  others  carrying  on  an  incoherent  discourse  with  imaginary 
persons,  fragments  of  which  often  relate  to  his  former  occupa- 
tion and  friends. 

Some  patients  do  not  present  this  picture  of  extreme  rest- 
lessness and  the  pressure  of  activity  is  not  communicated  to 
such  a  degree  to  the  function  of  speech.  Such  patients  may 
present  an  alert  appearance,  be  fairly  calm  and  can  often  be 
taken  in  the  lecture  room  before  the  class. 

The  mood,  too,  may  be  quite  different;  from  being  in  a 
condition  of  constant  apprehension  and  fear  of  an  overwhelm- 
ing and  terrifying  environment,  they  may  be  happy  and  con- 
tented. A  recent  patient  in  the  hospital  saw  about  him  numer- 
ous men  of  Lilliputian  dimensions  and  displayed  the  liveliest 
interest  in  these  strange  little  people. 

Often  dreamy  hallucinations  and  delusions  relate  altogether 
to  his  occupation  and  the  patient  busies  himself  with  his  usual 
pursuits — occupation  delirium.  Physically  he  is  in  a  condi- 
tion of  acute  exhaustion.  The  pulse  is  rapid  and  of  low  ten- 
sion, the  temperature  normal  or  only  slightly  elevated  (occa- 
sionally high,  the  febrile  delirium  tremens  of  Magnan),  the 
body  bathed  in  a  profuse  perspiration  and  constantly  agitated 
by  muscular  shocks  and  tremors.  Occasionally  one  sees  cases 
ushered  in  by  all  the  typical  prodromal  symptoms,  sweating, 
atonic  dyspepsia,  restlessness,  tremor,  precordial  distress,  anx- 
iety and  disturbed  sleep,  which  do  not  proceed  to  the  typical 
condition  of  mental  confusion  with  multiform  hallucinations. 
This  is  the  so-called  abortive  type,  the  delirium  sine  delirio  of 
Dollken. 

During  the  course  of  the  disease  almost  any  experience  the 
patient  may  have,  any  impression  made  upon  his  sensorium  is 
woven  into  the  warp  and  woof  of  his  delirious  experiences — 


THE   TOXIC    PSYCHOSES.  193 

sensory  flight  of  ideas.  Hallucinations  seem  to  arise  sponta- 
neously or  are  easily  produced  by  pressure  on  the  eyeball  or 
merely  by  getting  the  patient  to  look  at  a  blank  piece  of  paper. 
Paraphasia  and  paralexia  are  commonly  present. 

Albuminuria  is  found  in  a  considerable  proportion  of  cases, 
probably  considerably  over  fifty  per  cent.,  during  the  early 
stages.  At  the  height  of  the  delirium  leucocytosis  has  been 
found.  It  must  not  be  forgotten,  too,  that  here,  as  in  acute 
toxic  states  generally,  a  sluggish  reaction  of  the  pupil  to  light 
and  even  complete  Argyll-Robertson  pupil  may  be  found. 
This  sign  disappears,  however,  on  recovery.  This  is  an  im- 
portant fact  to  be  borne  in  mind  in  the  matter  of  diagnosis. 

Acute  cardiac  dilatation  may  develop  at  the  height  of  the 
disease. 

Course  and  Duration. — The  psychosis  runs  an  acute  course 
of  about  three  days  and  terminates  in  recovery  in  the  majority 
of  cases.  The  delirium  usually  ends  in  a  long  sleep.  About 
ten  to  fifteen  per  cent.  die. 

Chronic  Alcoholism. — The  effects  of  chronic  alcohol  poi- 
soning are  exhibited  in  every  organ  of  the  body,  more  par- 
ticularly the  central  nervous  organs,  stomach,  pancreas,  liver, 
kidneys  and  blood  vessels,  and  give  rise  to  characteristic  symp- 
toms as  a  result,  the  most  prominent  of  which  are  tremor, 
gastric  catarrh,  arterio-sclerosis,  albuminuria  and  progressive 
mental  enfeeblement. 

The  effects  on  the  nervous  system  are  shown  in  disturbances 
of  sensation,  motion  and  the  intellect.  The  sensory  disturb- 
ances are  paresthesia  (prickling,  tingling,  formication),  hyper- 
esthesia and  hyperalgesia,  occurring  usually  in  patches,  and 
anesthesia  also  of  patchy  distribution  but  sometimes  affecting 
only  one  side  (the  hemianesthetic  form  of  Magnan).  The 
sensory  disorders  of  the  special  senses  involve  principally  the 
eye  and  ear,  producing  illusions  and  hallucinations,  muscae 
volitantes,  photopsia,  amblyopia  and  amaurosis,  diminution  of 
the  acuteness  of  hearing  with  the  production  of  subjective 
14 


194  OUTLINES    OF    PSYCHIATRY, 

noises  (hissing,  ringing  roaring,  etc.),  due  to  middle  or  internal 
ear  disease. 

The  motor  disturbances  are  tremor,  spasms  and  cramps,  epi- 
leptiform attacks,  general  motor  enfeeblement  with  paresis. 

The  mental  changes  are  gradual  and  progressive,  the  intel- 
lect is  obtunded,  the  judgment  overthrown,  the  moral  sense 
blunted,  and  mendacity  appears  in  its  most  bizarre  forms; 
delusions  may  develop,  the  most  characteristic  of  which  is 
marital  infidelity  and  jealousy,  and  the  patient  sinks  gradually 
into  a  condition  of  permanent  mental  enfeeblement. 

Diagnosis. — Alcoholic  dementia  is  to  be  differentiated  from 
other  dementias  largely  by  the  history.  Alcoholic  dementia 
will  have  a  history  of  progressive  mental  enfeeblement  closely 
associated  with  alcoholic  indulgence. 

Alcoholic  Pseudo-Paresis. — On  a  groundwork  of  mental 
enfeeblement  the  alcoholic  may  develop  a  true  expansive 
delirium  which,  combined  with  the  signs  of  alcoholism  (ataxia, 
speech  defects,  tremor,  pupillary  anomalies  and  muscular  weak- 
ness), may  make  the  distinction  from  paresis  difficult — alco- 
holic pseudo-paresis.  This  similarity  to  paresis  is  noticeable 
even  when  the  expansive  delirium  is  absent  in  cases  in  which 
the  mental  reduction  is  marked,  but  becomes  greatest  when  the 
symptom  complex  above  outlined  is  ushered  in  by  epileptiform 
attacks. 

Diagnosis. — The  distinction  from  true  paresis  can  usually 
be  made.  Pupillary  inequality  is  more  common  and  the  per- 
manent results  of  apoplectic  insults  (hemiplegia,  aphasia)  more 
often  found  in  the  alcoholic  form  than  in  the  true.  The  results 
of  polyneuritis  should  be  looked  for  and  if  found  suggest 
alcoholism.  The  most  reliable  differential  sign  is  found  in  the 
course  of  the  two  maladies.  True  paresis  is  progressive,  tend- 
ing toward  ever-increasing  degradation,  while  in  the  alcoholic 
form  removal  of  the  poison  results  very  shortly  in  a  remission 
of  all  the  symptoms,  even,  in  some  cases,  amounting  to  a 
recovery.  The  symptoms,  however,  reappear  subsequently  if 
drinking  habits  are  returned  to. 


THE    TOXIC    PSYCHOSES.  195 

Alcoholic  Epilepsy. — As  a  result  of  chronic  alcoholic  tox- 
emia, the  symptoms  of  which  are  marked  throughout  by  their 
explosive  character,  it  is  not  strange  that  actual  convulsions, 
alcoholic  epilepsy,  should  complicate  the  morbid  picture.  These 
convulsions,  so  far  as  their  individual  characteristics  are  con- 
cerned, are  indistinguishable  from  true  epilepsy.  Occurring, 
however,  in  a  person  beyond  the  period  of  adolescence  who  is 
addicted  to  the  immoderate  use  of  alcohol,  their  origin  should 
be  suspected.  The  diagnosis  is  made  clear  if  they  cease  upon 
the  withdrawal  of  alcohol.  As  this  sometimes-  does  not  occur 
the  diagnosis  can  be  made  only  by  excluding  the  causes  both 
of  true  and  symptomatic  epilepsy  other  than  from  alcohol. 

Alcoholic  Hallucinosis. — This  psychosis  may  come  on  sud- 
denly in  a  chronic  alcoholic,  as  the  result  of  an  unusual  excess, 
or  it  may  be  of  gradual  evolution.  It  is  sometimes  preceded 
by  one  or  more  attacks  of  delirium  tremens.  It  is  character- 
ized by  hallucinations,  auditory  predominating,  thus  contrast- 
ing strongly  with  the  predominance  of  the  visual  hallucinations 
in  delirium  tremens. 

The  delusions  are  of  a  persecutory  nature,  in  which  the 
sexual  element  is  frequently  prominent  and  show  a  tendency  to 
systematization.  The  system,  however,  is  of  rapid  growth  and 
loosely  organized. 

Whether  of  sudden  or  gradual  onset,  the  first  symptoms  are 
hallucinations,  with  which  persecutory  delusions  are  intimately 
bound  up.  The  patient  hears  voices  making  all  sorts  of 
inimical  remarks,  telling  him  that  his  children  are  not  his  own, 
calling  him  an  onanist,  reviling  or  threatening  him.  A  voice 
is  sometimes  referred  to  the  epigastrium  (epigastric  voice), and 
in  every  way  his  persecutors  annoy  him  by  their  malign  com- 
ments. Visual  hallucinations,  if  they  occur,  are  equally  un- 
pleasant.    Hallucinations  of  smell  and  taste  are  not  infrequent. 

The  delusions  of  this  state  harmonize  well  with  the  halluci- 
nations. The  patient  is  persecuted  by  invisible  enemies  who 
inject  noxious  vapors  in  his  room  at  night,  poison  his  food, 
draw  off  his  semen,  and  produce  nocturnal  pollutions. 


ig6  OUTLINES    OF    PSYCHIATRY. 

In  this  state  of  persecutory  insanity  the  patient  is  depressed, 
apprehensive,  often  fearful  of  impending  danger,  may  have 
anxious  and  angry  states,  and  often  reacts  by  attacking  his 
supposed  persecutors.  Throughout  this  condition  the  patient 
is  well  oriented  and  consciousness  is  clear. 

Diagnosis. — The  diagnosis  from  delirium  tremens  is  made 
by  the  absence  of  disorientation  and  by  the  marked  prevalence 
of  auditory  hallucinations  in  the  form  of  threatening  voices. 
From  paranoia  the  distinction  is  made  by  the  very  rapid  sys- 
tematization  of  the  delusional  system,  as  opposed  to  the  slow 
evolution  of  that  disease. 

Alcoholic  Pseudo-Paranoia. — In  some  cases  of  chronic 
alcoholism  a  paranoid  state  is  developed,  in  which  psycho- 
sensory disturbances  (hallucinations)  may  be  of  secondary 
importance  or  not  present  at  all.  The  characteristic  delusion 
in  these  cases  is  that  of  marital  infidelity. 

While  some  of  these  cases  develop  primarily  upon  a  back- 
ground of  chronic  alcoholism,  others  may  follow  directly  upon 
an  attack  of  hallucinosis  or  delirium  tremens. 

These  cases  have  a  long  course,  poor  prognosis,  and  may  ter- 
minate in  considerable  impairment. 

Diagnosis. — This  delusion  of  marital  infidelity  and  jealousy 
may  not  be  accompanied  by  any  noticeable  degree  of  impair- 
ment of  judgment  or  mental  enfeeblement,  and  in  these  cases 
it  may  be  extremely  difficult  to  make  a  differential  diagnosis 
between  this  form  of  alcoholic  insanity  and  true  paranoia. 
Particularly  is  it  difficult  to  recognize  paranoia  with  subsequent 
or  coincident  alcoholic  indulgence. 

Certain  other  paranoid  conditions,  especially  of  the  involu- 
tion period,  may  present  this  picture  with  the  characteristic 
delusions  of  jealousy. 

Differentiation  is  made  by  excluding  alcohol  in  the  anamnesis. 

Korsakow's  Psychosis. — The  mental  state  of  this  psychosis 
accompanies  polyneuritis  and  is  usually  of  alcoholic  origin,  but 
may  be  caused  by  other  poisons,  as  those  of  typhus,  tubercu- 
losis, influenza,  and  the  Korsakow  syndrome  is  seen  not  infre- 


THE    TOXIC    PSYCHOSES.  197 

quently  in  general  paresis  and  in  senility.     The  signs  of  poly- 
neuritis may  be  very  slight. 

Syiiiptoiiis. — The  patient  is  amnesic  both  for  events  in  the 
immediate  past  and  for  the  whole  period  of  time  during  which 
he  has  been  ill.  This  defect  of  memory  is  associated  with  a 
composed  bearing  and  apparent  lucidity  on  casual  questioning. 
A  more  careful  examination,  however,  will  show  not  only  this 
memory  defect,  but  probably  also  that  the  patient  is  disoriented 
as  to  time  and  place. 

The  characteristic  symptom  is  associated  with  the  amnesia 
and  consists  of  a  peculiar  falsification  of  memory.  The  gaps 
in  memory  are  filled  by  all  sorts  of  fabrications  which  are  nar- 
rated in  great  detail  and  with  a  perfect  appearance  of  lucidity 
— confahulation.  A  patient  who  has  been  confined  to  his  bed 
for  days  with  foot-  and  wrist-drop  tells  me,  when  asked  where 
he  was  the  day  before,  about  having  gone  to  the  races  and 
details  his  conversation  with  different  persons,  describes  the 
events,  tells  what  horses  won  and  the  like. 

Diagnosis. — The  association  of  the  peculiar  falsification  of 
memory  with  confabulation  and  usually  disorientation  with 
foot-  and  wrist-drop  is  characteristic.  Paresis  is  to  be  distin- 
guished by  the  absence  of  evidences  of  polyneuritis. 

Dream  States. — Less  common  and  more  unusual  effects 
of  alcohol  are  the  conditions  of  so-called  trance,  automatism, 
double  consciousness,  spontaneous  somnambulism,  which  are 
followed  by  amnesia.  In  these  conditions  the  subject  of  alco- 
holism may  do  almost  anything  imaginable,  make  contracts, 
transfer  property,  commit  criminal  acts,  take  long  journeys, 
enter  into  complicated  business  or  professional  transactions, 
and  later  have  absolutely  no  knowledge  of  what  he  has  done. 
During  a  protracted  debauch  the  subject  may  suddenly  start 
off  on  a  journey  and  travel  under  an  assumed  name,  mean- 
while conducting  himself  in  such  a  manner  as  not  to  lead  to 
any  comment  on  the  part  of  those  whom  he  meets.  Suddenly, 
without  warning  or  after  a  night's  sleep,  he  "  wakes  up  "  to  a 
realization  of  his  true  situation  with  absolutely  no  memory  of 


198  OUTLINES    OF    PSYCHIATRY. 

how  he  got  where  he  is  or  what  he  has  been  doing  since  he 
started  away  from  home.  As  the  name  indicates,  this  condi- 
tion has  been  described  as  one  of  automatism,  but  a  moment's 
consideration  will  serve  to  show  that  acts  of  such  a  complex 
character  cannot  be  automatic  acts.  The  fact  that  no  recollec- 
tion remains  of  what  was  done  has  been  used  to  argue  uncon- 
sciousness, but  that  is  equally  inconceivable.  Hundreds  of 
miles  could  not  be  travelled  by  an  unconscious  man  without 
attracting  attention.  The  mere  fact  that  the  patient  has  for- 
gotten what  occurred  is  no  reason  why  he  must  necessarily 
have  been  unconscious.  I  have  been  fully  able  to  demonstrate 
that  consciousness  actually  did  exist  in  certain  cases  that  I 
have  studied  which  were  followed  by  amnesia,  and  as  a  result 
I  am  convinced  that  the  same  condition  might  be  found  to 
exist  in  others.  Some  persons  are  especially  liable  to  this  form 
of  mental  disturbance,  and  it  may  repeat  itself  on  the  occasion 
of  renewed  intoxication.  Its  psycho-pathological  basis  is  prob- 
ably a  dissociation  of  consciousness. 

The  neuropathic  state,  though  the  most  pronounced  cause  of 
alcoholism,  may  be  an  effect.  Neurasthenia  and  hysteria  may 
both  occur  as  the  result  of  alcoholism  ;  the  former  caused  largely 
by  the  malnutrition  and  exhaustion  following  continued  over- 
indulgences,  the  latter  often  affecting  the  male  sex.  In  these 
cases  the  alcohol  probably  only  serves  to  bring  to  light  latent 
hysteria. 

Dipsomania — a  periodical  impulse  to  drink — is  an  expres- 
sion of  deep-seated  neuropathic  taint. 

Course. — Chronic  alcoholism,  whether  interrupted  or  not  by 
any  of  the  forms  of  mental  disturbance  described  in  this  chapter, 
tends  to  an  ever-increasing  dementia,  alcoholic  dementia.  Men- 
tal enfeeblement  is  a  symptom  from  the  outset  and  is  notice- 
able at  first  in  the  esthetic  and  moral  sphere.  The  previously 
proud,  well-dressed  man  becomes  slovenly  in  his  habits  and 
unkempt  in  his  appearance.  Incapable  of  the  close  and  con- 
tinuous mental  application  of  former  years  it  becomes  impos- 
sible for  him  to  meet  the  requirements  of  his  business  or  pro- 


THE   TOXIC    PSYCHOSES.  199 

fessional  life  and  lying  is  resorted  to  in  finding  excuses.  This 
is  followed  by  moral  obliquities  of  a  more  serious  nature  in 
which  the  sexual  element  is  apt  to  predominate  and  result  in 
medico-legal  complications.  Memory  is  early  and  noticeably 
affected.  The  every-day  affairs  of  life  are  forgotten,  so  that 
the  subject  of  alcoholism  neglects  to  keep  appointments,  forgets 
important  business  engagements,  etc.  Judgment  and  the  rea- 
soning faculties  are  similarly  enfeebled,  until  finally  the  most 
profound  degree  of  dementia  is  reached,  hastened  perhaps  by 
apoplectic  insults  which  are  not  uncommon. 

Pathology. — The  gross  pathology  of  alcoholism  has  already 
been  indicated.  Cirrhotic  liver,  chronic  nephritis,  fatty  heart, 
chronic  gastritis,  arterio-capillary  fibrosis,  cerebral  arterio- 
sclerosis and  cerebral  hemorrhage. 

The  principal  lesions  found  in  the  brain  are  pachymeningitis, 
edema,  congestion,  thickening  and  opacity  of  the  piarachnoid, 
atrophy  of  the  convolutions,  sclerosis  of  the  vessels,  degenera- 
tion of  the  cells  and  increase  of  neuroglia. 

Treatment. — The  treatment  of  delirium  tremens  and  the 
other  acute  alcoholic  psychoses  should  be  supporting;  liquid 
concentrated  food  predigested  if  necessary.  The  bowels  should 
be  kept  free  and  the  kidneys  kept  flushed  by  a  goodly  supply 
of  fluid.  Heart  stimulants  are  often  necessary,  digitalis,  caf- 
feine, strychnine,  to  combat  cardiac  failure,  and  hypnotics  to 
induce  sleep  and  give  rest.  The  latter  should  be  carefully 
selected  with  reference  to  the  patient's  condition,  depressing 
agents,  such  as  chloral,  giving  place  to  safer  ones  as  trional 
if  there  is  much  heart  embarrassment.  The  after-treatment 
consists  of  abstinence  from  alcohol,  tonics,  nourishing  food 
and  regulation  of  the  emunctories. 

The  medicinal  treatment  of  chronic  alcoholism  should  be  tonic 
and  supporting.  Strychnine  for  a  general  nervous  and  cardiac 
stimulant,  ergot  if  there  be  symptoms  of  "wet  brain,"  cap- 
sicum and  bitter  tonics  for  the  gastric  condition  of  anorexia; 
attention  to  the  emunctories,  moderate  exercise,  baths,  massage 
and  electricity  for  their  general  tonic  effects;  sedatives  and 


200  OUTLINES    OF    PSYCHIATRY, 

hypnotics  with  caution ;  a  modified  "  rest  treatment "  if  there 
is  marked  neurasthenia,  and  later  a  sufficient  amount  of  mental 
and  bodily  exercise  to  keep  the  patient  healthfully  occupied. 

The  matter  of  isolation  is  an  important  one.  I  feel  con- 
vinced that  in  all  cases  in  which  the  habit  is  firmly  fixed  isola- 
tion is  highly  desirable,  if  not  imperative,  as  in  these  cases 
the  patient  is  unable  to  resist  temptation  and,  as  soon  as 
opportunity  presents  itself,  will  lapse.  After  confinement  for 
a  few  months,  during  which  the  patient  is  restored  as  far  as 
possible  to  physical  health,  he  is  in  condition  to  abstain  if  he 
wants  to  and  is  able;  if  he  does  not  wish  to  or  if  he  suffers 
from  too  great  weakness  of  will,  he  will  return  to  his  old  prac- 
tices and  his  case  is  hopeless.  If  he  does  wish  to  stop  drink- 
ing, however,  he  has  been  given  the  best  possible  opportunity, 
an  opportunity  which  should  be  early  extended  in  all  cases 
and  not  offered  when  by  long-continued  indulgence  the  case 
is  of  necessity  hopeless. 

Opiumism. 

Causes. — As  in  other  varieties  of  narcomania  the  most  im- 
portant cause  is  the  neuropathic  diathesis.  In  this  class  of 
patients  the  habit  is  often  initiated  by  the  use  of  morphine  to 
relieve  the  periodic  pains  of  neuralgia,  tabes,  dysmenorrhea, 
rheumatism,  etc.,  or  the  mental  depression  incident  to  worry, 
loss  of  position,  grief  and  the  like,  A  great  many  cases  are 
unfortunately  traced  to  the  carelessness  of  physicians  in  pre- 
scribing the  drug,  and  as  if  in  retribution  medical  men  furnish 
the  largest  quota  of  sufferers  (fifteen  per  cent,). 

Symptoms  and  Diagnosis. — The  symptoms  of  a  single 
dose  are  at  first  those  of  mild  stimulation  of  the  mental  facul- 
ties followed  by  a  period  of  quiet,  half-waking,  half-sleeping, 
interrupted  by  multiform  pleasant  hallucinations  (predomi- 
nantly visual)  which  show  no  tendency  to  delusive  elaboration 
in  the  waking  state.  This  condition  is  followed  by  malaise, 
headache,  dry  mouth,  constipation  and  nausea. 

The  physical  and  mental  disorders  resulting  from  long  con- 
tinued use  are  well  formulated  by  Peterson. 


THE    TOXIC    PSYCHOSES.  20I 

Physical. — (i)  Anorexia  and  constipation  (later  diarrhea 
often).  (2)  Cachectic  anemia.  (3)  Cardiac  intermittance 
and  bradycardia.  (4)  Muscular  weakness  with  tremor.  (5) 
Miosis  in  the  early  stages,  mydriasis  in  the  later,  with  sluggish 
reaction  of  the  pupils.  (6)  Impotence ;  amenorrhea  in  women. 
(7)  The  knee-jerks  are  often  absent.  (8)  Diminished  sensi- 
bility to  touch  and  pain  and  concentric  limitation  of  the  visual 
fields.  (9)  Headaches  and  localized  shooting  pains,  neuralgia 
and  paresthesias.      (10)  Sensation  of  being  cold. 

Psychical. — (i)  Simple  elementary  illusions  and  hallucina- 
tions, muscas  volitantes,  tinnitus  aurium.  (2)  Loss  of  will  and 
esthetic  sense,  irritability,  moral  perversion,  as  in  alcoholic 
ps5^chic  degeneration,  but  with  little  failure  of  memory.  (3) 
Diminished  attention,  incoherence  of  ideas  and  easily  fatigued 
intellectual  powers. 

The  diagnosis  can  often  not  be  made  without  the  anamnestic 
data.  The  patients  frequently  deny  their  habit — mendacity  is 
a  prominent  symptom,  and  they  are  often  cute  enough  to  find 
means  of  indulgence  even  though  carefully  watched.  The 
moral  degradation  is  pronounced  and  they  will  go  any  length 
to  obtain  their  drug.  Symptoms  which  should  excite  suspi- 
cion are  periods  of  torpor  and  languor  in  marked  contrast  to 
the  activity  of  alcoholism,  amounting  at  times  to  an  inability  to 
even  sit  up,  occasional  signs  of  stimulation,  small  pin-point 
pupils,  yellowish-brown  cachectic  complexion,  and,  above  all, 
the  numerous  scars  of  hypodermic  injections.  In  conditions 
in  which  a  diagnosis  is  necessary  it  is  to  be  remembered  that 
morphine  can  be  recovered  from  the  urine  and  stomach. 

Psychic  disturbances  develop  more  often  as  the  result  of 
abstinence  than  of  continued  use.  They  may  be  characterized 
by  predominating  depressive  (melancholia)  or  exalted  (mania) 
affects,  or  a  paranoid  state  may  develop.  As  in  other  toxic 
psychoses  there  are  apt  to  be  present  more  or  less  confusion 
and  a  tendency  to  multiform  hallucinations.  Dementia  is  a 
rare  sequel. 


202  OUTLINES    OF    PSYCHIATRY. 

Prognosis. — The  prognosis  is  not  good  and  except  in  such 
cases  as  are  not  compHcated  by  neurotic  or  psychopathic  taint 
or  disorders  reHeved  by  opium,  recovery  is  hardly  to  be  expected. 

Pathology. — Opium  has  much  less  tendency  to  produce 
tissue  degeneration  than  alcohol  and  many  persons  continue  for 
years  to  take  small  doses  with  no  apparent  harm. 

Treatment. — The  treatment  of  morphinism  has  to  do  with 
the  removal  of  the  drug  and  the  symptoms  of  abstinence.  Isola- 
tion is  more  necessary  than  in  alcoholism,  as  these  patients  make 
more  effort  to  obtain  their  accustomed  stimulant  surreptitiously. 
It  is  well,  in  accordance  with  Dercum's  suggestion,  not  to  begin 
stopping  the  drug  until  the  patient  has  been  under  treatment 
for  a  time,  confidence  established,  and  the  general  health  raised 
to  the  best  standard.  The  ration  de  luxe  can  then  be  rapidly 
withdrawn,  in  accordance  with  the  method  of  Erlenmeyer, 
leaving  the  patient  on  about  0.15  to  0.20  gm.  morphine  per 
diem,  below  which  amount  serious  symptoms  are  apt  to  present 
themselves.  From  this  point  on  the  withdrawal  should  be 
gradual.  Symptoms  of  abstinence,  if  they  appear,  are  refer- 
able to  the  heart,  stomach,  bowels  and  nervous  system ;  they 
are  circulatory  failure,  respiratory  disturbance,  pyrosis,  vom- 
iting, diarrhea,  tremor,  general  debility,  an  hallucinatory  de- 
lirium and  sometimes  profound  collapse.  Ball  has  called  atten- 
tion to  pollutions  and  erotomania  which  may  result  from 
abstinence.  For  the  cardiac  weakness  digitalis  or  sparteine 
hypodermically  should  be  used,  for  the  pyrosis,  bicarbonate  of 
soda;  vomiting  and  diarrhea  should  be  treated  in  accordance 
with  general  principles  (bismuth,  etc.),  opium  being  avoided. 
If  the  mental  and  physical  symptoms  become  grave  morphine 
should  be  given  and  will  usually  relieve  them.  The  evening 
dose  should  be  omitted  last,  to  combat  any  tendency  to  insom- 
nia, and  full  feeding,  massage  and  hydrotherapy  are  valuable 
adjuncts. 

Meco-narceine  (Duquesnel's  solution)  has  been  used  by 
Jennings  as  a  substitute  for  morphine  for  a  few  days  only 
after  entire  discontinuance.     It  is  necessary  to  call  attention  to 


THE    TOXIC    PSYCHOSES.  203 

the  danger  of  cocaine  for  this  purpose.  Codeine  has  also  sunk 
into  disuse  and  the  recently  synthetized  derivatives  of  mor- 
phine, heroin  and  dionin  cannot  be  said  to  be  any  better.  Their 
use  is  founded  on  a  wrong  theory  and  is  fraught  with  danger. 
Cases  of  serious  addiction  to  codeine  and  heroin  have  been 
reported. 

Cocainism. 

Causes. — Addiction  to  this  drug  has  in  a  great  many  cases 
come  about  by  attempting  to  substitute  it  for  morphine,  and  as 
a  result  pure  cases  of  cocainism  were  formerly  more  rare  than 
at  present.  Cocaine  has  been  used  so  much  of  late  in  dentistry, 
minor  surgery,  and  especially  nose  and  throat  work,  that  a 
knowledge  of  it  has  become  more  or  less  general.  The  victims 
are  usually  those  who  have  commenced  its  use  for  its  analgesic 
effects  and  are  largely  physicians. 

Symptoms. — The  symptoms  resulting  from  the  use  of  co- 
caine are  those  of  marked  stimulation.  The  pulse  is  increased, 
pupils  are  dilated.  The  patients  are  active  and  extremely 
talkative,  often  repeating  remarks  a  number  of  times ;  they  are 
constantly  busy,  some  of  them  writing  endless  letters,  and  their 
whole  appearance  indicates  an  acute  intoxication.  The  effects 
are,  however,  very  fleeting  and  the  dose  has  to  be  frequently 
renewed.  Chronic  addictions  result  in  marked  emaciation, 
cachectic  anemia,  insomnia,  sometimes  epileptiform  attacks  and 
various  paresthesias,  the  most  marked  of  which  is  a  sensation 
of  crawling  under  the  skin  ("cocaine  bug").  In  the  psychic 
sphere  occur  incapacity  for  mental  application,  lessened  moral 
sense,  mendacity,  irritability,  impaired  judgment  and  sometimes 
the  delusion  of  marital  infidelity.  These  symptoms  may  be 
followed  by  mental  confusion  with  hallucinations,  but  more 
characteristically  by  a  paranoid  state.  From  true  paranoia 
this  is  differentiated  by  the  greater  variety  of  delusions,  those 
of  paranoia  being  less  variable,  rather  noticeable  for  their 
monotony.  In  the  paranoid  state  of  alcoholism,  on  the  other 
hand,  the  hallucinations  are  more  stereotyped. 

The  abstinence  symptoms  are  not  so  severe  as  with  mor- 


204  OUTLINES    OF    PSYCHIATRY. 

phine  and  may  not  appear  for  several  days.  Erlenmeyer  has 
called  attention  to  a  profoundly  depressed,  lachrymose,  demor- 
alized condition,  with  moaning  and  sighing  which  may  super- 
vene. The  persecutory  delirium  may  persist  for  a  long  time 
and  constitute  the  patient  a  very  dangerous  individual. 

Morphine  and  cocaine  addiction  may  also  produce  a  neuro- 
psychopathic state,  with  symptoms  of  cerebral  neurasthenia — 
morbid  impulses,  insistent  ideas,  etc.  The  author  has  recently 
had  such  a  case  under  observation,  in  which  the  patient  suf- 
fered from  a  convulsive  tic  with  mental  depression  and  sui- 
cidal impulse.     Recovery  followed  prolonged  abstinence. 

Treatment. — Isolation  should  be  insisted  upon.  The  drug 
may  be  withdrawn  rapidly  as  the  symptoms  of  abstinence  are 
not  marked  as  in  morphine.  The  prognosis  of  deprivation  is 
good,  but  relapses  are  pretty  apt  to  occur. 

Miscellaneous  Intoxicants. 

Various  other  drugs  may  produce  marked  mental  disturb- 
ances as  a  result  of  acute  or  chronic  poisoning  or  habituation. 
The  limits  of  this  work  permit  only  of  their  mention.  They 
are  chloral,  cannabis  indica,  somnal,  sulfonal,  paraldehyde, 
ether,  chloroform,  antipyrin,  phenacetin,  trional,  chloralamid, 
iodoform,  belladonna,  hyoscyamus,  salicylic  acid,  quinine,  the 
preparations  of  lead,  arsenic  and  mercury  and  the  bromides. 

The  mental  effects  of  poisoning  from  all  of  these  is  in  the 
main  an  acute  hallucinatory  confusion.  If  recovery  is  not 
prompt  a  paranoid  state  may  persist  for  a  variable  period. 


CHAPTER   XVI. 

PSYCHOSES  ASSOCIATED  WITH  OTHER 
DISEASES. 

The  Neuroses. 

The  so-called  neuroses,  especially  hysteria  and  neurasthenia, 
might  properly  be  classed  with  the  psychoses  and  designated  as 
psycho-neuroses,  as  mental  symptoms  are  almost  invariably 
present  and  in  hysteria  and  neurasthenia  especially  form  part 
of  the  symptom-complex. 

Hysteria. — The  mental  symptoms  of  hysteria  may  be  divided 
into  those  constant  phenomena  which  are  present  throughout 
the  course  of  the  malady — the  symptoms  of  the  interparoxys- 
mal  period,  the  so-called  mental  stigmata,  and  those  more 
or  less  closely  connected  with  the  paroxysms — the  episodic 
phenomena. 

Mental  Stigmata. — The  principal  symptoms  of  the  inter- 
paroxysmal  period  are :  Anesthesias — disseminated,  segmental, 
hemianesthesia,  hyperesthesias  usually  disseminated.  Motor 
disturbances — contractions,  catalepsy,  paralysis.  Amnesias — 
partial  or  general.  Debility  of  the  emotions — loss  of  will 
pozcer,  suggestibility. 

It  must  be  fully  understood  that  all  these  symptoms,  even 
the  sensory  and  motor  disturbances,  are  purely  mental. 

Episodic  Phenomena. — These  phenomena  may  precede  or 
follow  an  hysterical  crisis,  or,  as  in  epilepsy,  may  be  substituted 
for  one.  They  are  principally  states  of  exaltation,  depression, 
delusions,  lethargy,  somnambulism,  fixed  ideas,  delirium,  chore- 
iform movements. 

Conditions  of  delirium  with  great  confusion,  clouding  of 
consciousness  and  hallucinations  are  common. 

Dream  states  are  also  quite  characteristic  of  this  disease,  as 
they  are  of  epilepsy  and  alcoholism. 

205 


206  OUTLINES    OF    PSYCHIATRY. 

A  characteristic  of  these  episodic  manifestations  is  their  very 
frequent  association  with  amnesia. 

It  will  often  be  found  that  the  crises  of  hysteria  are  asso- 
ciated with  certain  sub-conscious  ideas,  usually  connected  with 
some  previous  experience,  having  a  large  content  of  painful 
emotion,  which  has  been  forgotten. 

In  fact  the  psychology  of  hysteria  is  the  psychology  of  these 
sub-conscious  states  and  their  method  of  growth  by  a  process 
of  dissociation,  or  splitting  of  the  normal  consciousness.  Fol- 
lowing these  periods  of  sub-conscious  activity  the  patient  may 
have  absolutely  no  recollection  of  what  has  occurred,  so  that 
the  phenomena  have  often  been  looked  upon  as  disturbances 
of  memory. 

While  in  the  normal  individual,  however,  memories  lapse  by 
a  process  of  gradual  subsidence  in  the  face  of  the  intensive 
present,  in  these  other  conditions  the  events  cannot  be  said  to 
lapse  in  this  way  as  they  no  longer  are  in  direct  connection  with 
the  personal  consciousness.  In  these  instances  a  dissociation 
has  taken  place,  there  has  been  a  fault,  a  line  of  cleavage  which 
separates  them  much  more  completely. 

This  cleavage  with  the  resulting  dissociation  is  an  abnormal 
phenomenon  and  the  manifestations  which  follow  result  from  a 
split-off  state  in  the  sub-conscious  which  tends  always  to  be- 
come dynamic. 

This  condition  of  dissociation  has  its  origin  in  a  severe  emo- 
tional shock,  or  in  a  series  of  small  shocks.  It  occurs  more 
particularly  in  young  people,  being  more  readily  brought  about 
in  that  condition  of  lability  incident  to  development  and  as  at 
this  time  the  sexual  preempts  a  very  prominent  place  in  mental 
life  the  resulting  picture  is  correspondingly  colored. 

The  dissociation  in  its  beginning  may  be  of  any  extent.  A 
certain  portion  of  the  then  consciousness  of  the  individual  at 
the  time  of  the  accident  is  separated  by  a  plane  of  cleavage  from 
his  subsequent  mental  existence  and  in  relation  to  that  mental 
existence  is  said  to  be  sub-conscious. 

The  process  of  dissociation,  having  once  begun,  tends  to  con- 


PSYCHOSES   ASSOCIATED    WITH    OTHER   DISEASES.  20/ 

tinue  and  new  material  is  constantly  being  added  to  this  sec- 
ondary state  by  further  cleavage  and  also  by  assimilation  by 
this  state  itself  as  it  begins  to  lead  an  independent  existence. 
Thus  the  tendency  is  for  it  to  continually  grow,  and  when  that 
growth  takes  place  by  repeated  cleavage,  to  grow  at  the  ex- 
pense of  the  personal  consciousness. 

This  is  the  process  of  dissociation  but  associated  with  it  is 
the  dynamogenic  quality  of  the  dissociated  states  spoken  of 
above  and  which  is  responsible  largely  for  the  manifestations 
that  have  attracted  attention.  How  can  this  factor  be  ex- 
plained ? 

In  the  normally  functioning  mind  there  is  constantly  going 
on  a  "  battle  of  motives,"  a  struggle  for  supremacy  between  the 
several  elements,  much  like  the  struggle  recently  described  as 
between  the  physical  elements  of  the  body  which  results  in 
certain  structural  types.  The  result  of  this  is  that  differences 
of  tension  tend  to  occur  in  different  areas,  but  as  these  areas 
are  all  organically  connected,  discharge  taking  place  along  the 
lines  of  least  resistance  drains  those  at  high  tension.  Inhibi- 
tion by  drainage  (McDougall)  occurs. 

Now  in  these  dissociated  states,  separated  from  the  personal 
consciousness  by  a  plane  of  cleavage  a  plus  tension  finds  no 
relief.  The  energy  not  being  drained  as  normally,  accumulates 
to  the  point  of  explosion,  and  breaking  over  the  gap  which 
separates  it  from  the  upper  strata  manifests  itself  in  waves  of 
disturbance  therein.  Thus  we  have  the  phenomena  of  epilep- 
tiform and  hysteriform  crises,  transient  deliria,  episodic  depres- 
sions and  a  multitude  of  other  sensori-motor  expressions.  These 
expressions  recur  and  naturally  tend  to  become  periodic. 

On  the  other  hand,  during  periods  of  inactivity  of  the  upper 
consciousness,  as  in  hypnotic,  hypnoidal  (Sidis)  and  dream 
states  the  secondary  states  tend  to  assume  the  ascendancy. 

Whether  the  secondary  states  ever  assume  the  dignity  of  a 
personality  or  not  is  merely  a  question  of  degree.  They  tend 
to  organize  and  to  grow  and  if  the  process  keeps  up  it  is  only 
a  question  of  time  when  a  new  personality  will  be  born.     If 


208  OUTLINES    OF    PSYCHIATRY. 

these  states  grow  largely  at  the  expense  of  the  personal  con- 
sciousness this  latter  may  finally  assume  a  relative  position  of 
inferiority. 

Diagnosis. — Epilepsy  is  the  most  difficult  disease  from  which 
to  differentiate  hysteria.  This  is  particularly  so  because  of  the 
convulsive  attacks  in  each.  The  diagnosis  must  often  rest 
upon  the  presence  of  the  hysterical  stigmata  in  the  inter- 
paroxysmal  period,  as  the  attacks  are  often  not  seen  and  cannot 
be  distinguished  by  the  description  given.  The  presence  of 
these  stigmata  will  usually  suffice,  as  hysterical  convulsions  and 
true  epileptic  convulsions  seldom  occur  in  the  same  patient. 
Hysterio-epilepsy  is  not  a  combination  of  the  two  diseases,  but 
hysteria  with  associated  epileptiform  attacks. 

The  differentiation  from  the  other  psychoses  is  to  be  made 
from  the  history  and  the  presence  of  hysterical  stigmata. 

Treatment. — The  principle  of  treatment  is  to  reestablish  the 
broken  associations.  This  is  generally  best  accomplished  by 
inducing  a  semi-sleeping  state — the  hypnoidal  state  of  Sidis — 
tapping  the  sub-conscious  in  this  way,  and  then  by  a  gradual 
arousing  of  the  patient  bridging  the  gap  between  it  and  the 
upper  consciousness.  (The  subject  is  somewhat  too  extensive 
to  go  into  further  in  a  work  of  this  character. ) 

Neurasthenia. — Symptoms:  Like  hysteria  the  manifesta- 
tions of  neurasthenia  are  protean  and  numerous.  The  disease 
may  be  hereditary,  constituting  so-called  constitutional  neuras- 
thenia, or  it  may  be  acquired  by  exhausting  and  debilitating 
conditions,  usually  acting  over  a  considerable  period.  Symp- 
toms of  hysteria  are  not  infrequently  combined  with  those  of 
neurasthenia,  constituting  hystero-neurasthenia.  Neurasthenia 
is  usually  classified  in  accordance  with  the  organs  about  which 
the  symptoms  most  prominently  group  themselves  into  cere- 
bral, spinal,  genital,  gastric,  angiopathic,  or  in  accordance  with 
the  cause  as  lithmnic  and  traumatic. 

The  symptoms  are  those  of  fatigueahility  and  depression, 
with  special  symptoms  associated  with  the  viscera,  such  as  dys- 
pepsia, diarrhea,  headache,  various  paresthesias,  particularly 


PSYCHOSES    ASSOCIATED    WITH    OTHER   DISEASES.  209 

band-like  and  pressure  sensations  of  the  head.  The  depres- 
sion is  often  associated  with  hypochondriacal  ideas,  phobias, 
obsessions,  fixed  ideas  and  impulsions. 

Diagnosis. — The  diagnosis  must  be  made  from  the  early- 
stages  of  paresis  and  dementia  precox,  and  from  the  depressive 
stage  of  manic-depressive  insanity. 

Treatment. — In  the  main  the  treatment  should  be  tonic  and 
restorative.  The  Weir  Mitchell  rest  cure  is  effective  in  many 
of  these  cases  and  accomplishes  its  results  quite  as  much,  in 
many  cases,  because  of  the  effect  on  the  mind  of  the  patient  as 
because  of  the  result  in  improvement  of  bodily  health.  This 
group  of  cases  are  especially  favorable  for  a  rational  psycho- 
therapy. 

Epilepsy. — The  mental  disturbances  associated  with  and  due 
to  epilepsy  may  be  considered  as  divided  into  the  paroxysmal 
and  the  inter  paroxysmal. 

Paroxysmal. — These  are  either  associated  with  the  attack — 
unconsciousness,  psychic  epilepsy  (dream  states,  automatism, 
furious  maniacal  attacks  followed  by  complete  amnesia) — or 
else  pre-  and  post-epileptic  attacks,  often  of  a  maniacal  order, 
but  frequently,  especially  following  an  attack,  being  delirious. 
Amnesia  follows  all  these  states. 

Intcrparoxysmal. — These  symptoms  go  to  make  up  the  epi- 
leptic character.  They  are,  in  the  main,  transitory  attacks  of 
ill-humor,  sometimes  violent  temper  and  impulsiveness,  asso- 
ciated with  a  certain  degree  of  dementia,  manifested  by  dull- 
ness, apathy,  unreasonableness,  with  frequently  associated  relig- 
ious fervor.  Delusional  states  not  infrequently  occur.  If  the 
epilepsy  has  begun  in  early  life  a  degree  of  imbecility  or  idiocy 
results. 

Diagnosis. — These  various  mental  conditions  are  diagnosed 
by  a  careful  study  of  the  history  and  the  presence  of  undoubted 
epileptic  convulsive  seizures.  Differential  diagnosis  must  be 
made  from  hysteria,  catatonia,  the  delirium  of  alcohol  and 
other  intoxicants  and  infections,  and  from  the  delirious  states 
of  paresis. 
15 


2IO  OUTLINES    OF    PSYCHIATRY. 

Treatment. — The  treatment  is  the  treatment  of  epilepsy. 
When  dangerous  tendencies  are  associated  with  the  attacks  the 
patient  should  be  confined  in  an  appropriate  institution. 

Other  Nervous  Diseases. 

Chorea:  Sydenham's  Chorea. — Patients  with  chorea  are 
usually  impatient,  irritable  and  emotionally  unstable.  Some 
of  the  cases  develop  terrifying  dreams  and  hallucinations,  espe- 
cially at  night.  Marked  psychotic  symptoms  develop  in  the 
variety  of  the  disease  known  as  chorea  insaniens,  an  acute  con- 
fusion, sometimes  of  violent  type,  develops  with  hallucinations 
and  often  a  paranoid  condition  with  delusions  of  persecution. 
Sometimes  a  condition  of  stupor  is  observed. 

Diagnosis. — The  diagnosis  is  made  by  the  association  of  the 
mental  symptoms  with  the  characteristic  choreic  movements. 

Huntington's  Chorea. — This  disease  is  associated  on  the  psy- 
chical side  with  gradual  mental  impairment. 

Paralysis  Agitans. — This  disease  is  often  associated  with  a 
mild  degree  of  mental  enfeeblement. 

Multiple  Sclerosis. — The  mental  condition  is  usually  one 
of  slight  impairment,  especially  with  emotional  instability. 
The  patient  laughs  and  cries  very  easily. 

Diagnosis. — The  disease  must  be  differentiated  from  paresis 
which  it  often  closely  resembles. 

Polyneuritis. — See  Korsakow's  Psychosis,  Chapter  XV. 

Treatment. — The  treatment  of  all  these  conditions  is  the 
treatment  of  the  underlying  disease. 

Organic  Diseases  and  Injury  of  the  Brain. 

Tumor. — Mental  symptoms  are  more  apt  to  occur  when  the 
tumor  is  located  in  the  pre-frontal  region.  They  are  change  of 
character,  irritability,  childishness,  emotional  instability,  with 
a  tendency  to  hebetude  and  some  clouding  of  consciousness. 
Hallucinations  may  develop  as  the  result  of  the  invasion  by  the 
growth  of  sensory  areas. 

Diagnosis. — The  diagnosis  is  made  from  the  presence  of  the 


PSYCHOSES   ASSOCIATED    WITH    OTHER   DISEASES.  211 

classical  symptoms  of  tumor  and  a  study  of  the  localizing 
symptoms.  The  disease  most  apt  to  be  confounded  with  tumor 
is  paresis.  Cases  are  seen  on  the  one  hand  to  present  quite 
clear  local  symptoms  and  subsequently  turn  out  to  be  paresis; 
while  on  the  other  hand  cases  are  seen  without  local  symptoms 
and  which  appear  to  be  paresis  but  which  turn  out  to  be  tumor. 

Syphilis. — An  acute  delirium  may  develop  during  the  early 
secondary  manifestations  of  the  disease.  Later  marked  mani- 
festations may  be  connected  with  local  or  general  disease  of 
the  brain.  Gumma  are  rare  and  give  the  symptoms  of  tumor. 
The  most  common  condition  is  a  progressive  disease  of  the 
cerebral  vessels,  often  with  thrombosis. 

The  mental  symptoms  are  those  of  dementia,  to  which  are 
added  local  symptoms  as  a  result  of  thrombosis.  The  symp- 
toms will  of  course  vary  according  to  the  location  of  the 
softening. 

Diagnosis. — Many  of  these  cases  are  extremely  difficult  to 
differentiate  from  paresis.  Brain  syphilis  occurs  a  shorter 
period  after  luetic  infection,  is  more  marked  by  localizing  symp- 
toms, especially  ocular  palsies,  often  is  associated  with  severe 
headaches,  which  are  usually  worse  at  night,  and  the  symp- 
toms, with  the  exception  of  those  due  to  destructive  lesions, 
yield  to  anti-syphilitic  medication. 

It  must  not  be  forgotten  that  a  sluggish  light  reflex  and 
even  an  Argyll-Robertson  pupil  may  be  found  in  cerebral  lues. 

Apoplexy. — The  mental  condition,  following  apoplexy  is 
usually  one  of  impairment  which,  if  the  lesion  is  considerable, 
progresses  to  marked  dementia.  If  the  softening  involves  the 
speech  area,  especially  if  it  produce  sensory  aphasia,  the  de- 
mentia is  much  more  rapid  in  progress,  as  it  must  be  remem- 
bered that  these  patients  are  usually  senile.  Epilepsy  often 
develops  as  a  result  of  a  localized  area  of  softening. 

Arterio-sclerosis. — This  condition  is  associated  with  a  pro- 
gressive failure  of  the  mental  faculties  and  local  symptoms,  due 
to  areas  of  softening.  Because  of  the  diffuseness  of  the  lesions 
the  picture  often  closely  resembles  paresis,  but  the  patient  is 


212  OUTLINES    OF    PSYCHIATRY. 

much  further  advanced  in  years  than  is  usual  for  the  paretic. 
Cerebral  arterio-sclerosis  furnishes  the  connecting  link  between 
the  psychoses  of  involution  and  of  the  senium.  Many  of  the 
late  depressions  present  the  picture  of  beginning  senility,  and 
in  general  the  later  the  depressions  come  on  the  worse  the  prog- 
nosis, while  many  of  these  cases  drift  over  into  a  senile,  or 
arterio-sclerotic  dementia. 

Alzheimer  has  described  four  varieties  of  the  disease  which 
are  to  an  extent  differentiated  clinically.  These  varieties  and 
their  differentiations  are  well  summarized  by  Barrett. 

1.  Arterio-sclerotic  Brain  Atrophy. — This  occurs  in  two 
forms,  a  mild  form  with  severe  arterial  sclerosis  but  an  absence 
of  focal  brain  lesions.  The  symptoms  are  easy  fatigue,  slight 
failure  of  memory,  dizziness  and  headache.  The  severe  type 
may  resemble  the  mild  at  first  but  is  progressive,  leads  to  pro- 
found dementia  and  presents  in  its  course  apoplectiform  and 
epileptiform  attacks  and  focal  symptoms. 

2.  Subcortical  encephalitis  of  Binzwanger.  In  this  condi- 
tion the  white  matter  is  largely  involved  as  a  result  of  the  dis- 
ease in  the  long  medullary  arteries.  Apoplectiform  and  epi- 
leptiform attacks  occur  and  also  transitory  attacks  of  confusion, 
aphasia  and  paresis,  disturbances  suggesting  focal  lesions. 
Focal  lesions  are  not  found  extensively  but  areas  of  softening 
often  occur  in  the  basal  ganglia. 

3.  Perivascular  Gliosis. — In  this  condition  there  is  a  disap- 
pearance of  nervous  elements  about  the  diseased  vessels  and 
replacement  by  neuroglia. 

4.  Senile  Cortical  Devastation. — Here  we  find  extensive 
destruction  of  cortical  areas  in  the  vascular  territories  of  the 
diseased  vessels. 

Diagnosis. — The  disease  most  apt  to  be  confounded  with 
arterio-sclerotic  dementia  is  paresis.  It  is  extremely  difficult 
to  differentiate  many  cases  of  paresis  with  focal  lesions.  In 
general  paresis  occurs  earlier  in  life  and  presents  more  uniform 
impairment. 

Treatment. — In  the  main  the  treatment  should  be  to  so  regu- 


PSYCHOSES   ASSOCIATED    WITH    OTHER   DISEASES.  213 

late  the  life  as  to  take  all  unnecessary  strain  from  the  cardio- 
vascular symptom.  Easily  assimilated  food,  care  of  the  emunc- 
tories,  moderate  exercise,  freedom  from  worry  and  from  mental 
or  physical  exertion.  For  the  insomnia  alcohol  in  the  form  of 
a  small  dose  of  whiskey  and  water  at  night  is  excellent,  but 
should  be  given  with  great  care  and  its  administration  carefully 
guarded,  as  these  patients  are  especially  susceptible  to  it  and 
often  develop  periods  of  confusion  from  very  small  doses. 

Traumatism.  —  The  most  frequent  symptoms  following 
trauma  are  those  of  hysteria  and  neurasthenia.  Dementia 
precox,  manic-depressive  insanity  and  paresis  may  follow  an 
injury. 

After  the  injury  a  delirium  may  develop.  Aside  from  this, 
mental  symptoms  may  not  occur  for  a  considerable  time,  and 
when  they  do  they  usually  consist  of  an  apathetic  dementia 
with  often  irritability.  There  are  often  memory  defects,  espe- 
cially amnesia  for  the  time  of  the  injury,  and  these  defects  may 
be  filled  in  with  fabrications.  There  is  almost  always  intoler- 
ance of  alcohol. 

Meyer  classifies  the  effects  of  traumatism  in  the  nervous 
system  as  follows : 

1.  The  direct  focal  and  the  more  diffuse  destruction  of  the 
nerve-tissue  or  of  parts  of  it;  and  the  reaction  of  the  tissues. 

(a)  The  immediate  effects — edema. 

(b)  The  scar  formation. 

2.  The  distinctly  diffuse  commotions  in  which  the  general 
reaction  and  the  psychic  elements  preponderate,  including  the 
remote  reactive  results  of  exaggerations  of  vasomotor  and  emo- 
tional responsiveness. 

He  classifies  the  psychoses  developing  as  follows : 
I.  Post-traumatic  delvria,  including  febrile  reactions,  the 
delirium  nervosum  of  Dupuytren,  not  differing  from  post- 
operative delirium,  the  delirium  of  the  slow  solution  of  coma  in 
alcoholic  as  well  as  non-alcoholic  subjects,  protracted  deliria 
with  confabulation  with  or  without  alcoholic  or  senile  basis. 


214  OUTLINES    OF    PSYCHIATRY. 

2.  Post-traumatic  Constitution. — Excessive  reaction  to  alco- 
hol, la  grippe,  etc.,  the  vasomotor  neurosis  of  Friedman,  the 
"  explosive  diathesis  "  of  Kaplan,  hysteroid  or  epileptoid  epi- 
sodes, with  or  without  convulsions,  paranoid  states. 

3.  Traumatic  Defect  Conditions.  —  Conditions  allied  to 
aphasia,  deterioration  with  epilepsy,  deterioration  due  to  the 
progressive  alteration  of  the  primarily  injured  parts,  with  or 
without  arterio-sclerosis. 

4.  Psychoses  in  ivhich  trauma  is  merely  a  contributory  fac- 
tor.— Paresis,  manic-depressive,  dementia  precox. 

5.  Traumatic  psychoses  from  injury  not  directly  affecting 
the  head. 

Diseases  Other  Than  Nervous. 

Various  other  diseases  have  from  time  to  time  mental  symp- 
toms associated  with  them.  The  great  majority  of  such  dis- 
eases, if  not  all  of  them,  have  elements  of  infection  or  toxemia 
and  exhaustion  combined  with  or  part  of  them.  We  therefore 
see  the  mental  symptom  complex  of  confusion  arise  most  typi- 
cally. In  some  cases,  especially,  the  less  acute  paranoid  condi- 
tions occur  and  hallucinosis  is  of  occasional  occurrence. 

Head  has  recently  shown  that  certain  visceral  diseases,  espe- 
cially of  cardio-vascular  and  pulmonary  origin,  often  have 
associated  mental  symptoms,  although  they  may  not  appear 
except  on  the  most  careful  examination.  The  symptoms  found 
are:  (i)  Hallucinations  of  vision,  hearing  and  smell;  (2) 
moods,  either  of  depression  or  exaltation,  and  (3)  suspicions, 
usually  occurring  when  a  depression  has  persisted  for  some 
time. 

These  conditions  take  their  origin  as  a  result  of  reflected 
visceral  pains.  Each  spinal  segment  has  both  a  visceral  and 
a  cutaneous  representation.  Disease  occurring  in  the  visceral 
area  is  referred  to  the  cutaneous  surface  supplied  by  the  same 
segment.  The  cutaneous  distribution  of  the  fifth  nerve  corre- 
sponds to  the  visceral  distribution  of  the  vagus,  so  pain  occur- 
ring in  the  vagus  territory  will  be  referred  to  the  scalp  and  thus 


PSYCHOSES    ASSOCIATED    WITH    OTHER   DISEASES.  215 

occur  points  of  tenderness  in  this  region  with  which  the  hallu- 
cinations are  associated.  The  mood  of  exaltation  is  essentially 
transitory  and  arises  as  a  contrast  phenomenon  of  the  depres- 
sion and  as  a  result  of  the  disappearance  or  lessening  of  the 
reflected  somatic  pain. 


CHAPTER   XVII. 

BORDERLAND   AND   EPISODIC   STATES. 

Psychasthenia. — Under  this  term  Janet  includes  obsessions, 
impulsions,  insanity  of  doubt,  tics,  agitations,  phobias,  delirium 
of  contact,  anguishes,  neurasthenias  and  the  bizarre  feelings  of 
strangeness  and  of  depersonalization  often  described  under  the 
name  of  cerebro-cardiac  neuropathy  or  disease  of  Krishaber. 
By  considering  all  of  these  varied  conditions  together  as  results 
of  a  fundamental  underlying  state  he  would  thus  erect  psychas- 
thenia into  a  psycho-neurosis. 

This  psycho-neurosis  has  as  its  fundamental  symptom  the 
lowering  of  the  psychologkal  tension.  If  we  can  think  of  our 
mental  force  in  mechanical  terms  and  conceive  of  it  as  flowing 
along  the  fiber  tracts  like  steam  in  a  pipe,  then  we  may  believe 
that  this  force  has  to  be  maintained  at  a  certain  tension  in 
order  that  the  perceptions  from  the  outside  world  may  be 
appreciated  at  their  true  value.  If  attention  is  lowered  the 
perceptions  are  not  acute.  This  lack  of  acuteness  gives  origin 
to  feelings  on  the  part  of  the  patient  of  incompleteness  and 
insufficiency.  Now  this  state  of  affairs  involves  a  certain 
deficiency  in  the  perception  of  reality  which  requires  a  certain 
concentration  and  complexity  of  content,  in  other  words,  a  high 
psychological  tension. 

This  lowering  of  psychological  tension,  feeling  of  incom- 
pleteness and  deficiency  in  the  "  function  of  the  real "  consti- 
tutes the  fundamental  common  feature  of  all  this  class  of 
phenomena. 

The  lowered  tension  gives  rise  to  various  symptoms  in  pro- 
portion to  the  degree  of  lowering.  If  the  mental  functions  are 
erected  into  a  hierarchy  in  proportion  to  the  difficulty  of  their 
accomplishment  it  will  be  seen  that  the  accurate  estimation  of 

216 


BORDERLAND   AND   EPISODIC    STATES.  21/ 

reality  stands  first,  revery  and  imagination  come  lower  down, 
and  muscular  movements  last.  As  the  tension  is  lowered 
reactions  will  tend  to  follow  in  the  order  of  this  psychological 
hierarchy. 

Psychasthenia  stands  midway  between  epilepsy  and  hysteria. 
In  both  psychasthenia  and  epilepsy  the  fundamental  condition 
Janet  thinks  is  this  lowering  of  psychological  tension.  In  epi- 
lepsy this  lowering  is  sudden,  very  profound,  leading  even  to 
unconsciousness,  and  is  then  practically  completely  recovered 
from,  while  in  psychasthenia  it  is  more  or  less  constant  but  of 
much  less  degree.  Thus  psychasthenia  is  attenuated  and  chronic 
epilepsy.  Hysteria,  on  the  other  hand,  is  characterized  by  a 
"  retraction  of  the  field  of  consciousness."  While  in  psychas- 
thenia the  defect  is  more  or  less  uniform  over  the  whole  field 
of  consciousness,  in  hysteria  the  portions  of  the  field  retained 
may  be  quite  up  to  normal  or  even  hyper-normal. 

The  classification  of  the  various  symptoms  of  psychasthenia 
is  difficult  because  of  their  multiplicity  and  variability.  Using 
the  word  obsessions  in  a  broad  sense  to  include  the  conditions  I 
have  described  as  obsessions,  fixed  ideas  and  impulses,  in  the 
chapter  on  General  Symptomatology,  because  of  the  desirability 
of  considering  them  under  different  heads,  we  may  divide 
obsessions  into  emotiofml,  intellectual  and  impulsive,  in  accord- 
ance with  their  predominating  characters,  realizing  meantime 
that  the  distinctions  are  only  general  ones  and  the  lines  of  dif- 
ferentiation not  hard  and  fast. 

Emotional  obsessions  include  the  various  phobias  and  the 
morbid  desires.  Some  of  the  more  common  phobias  are  agora- 
phobia, fear  of  open  places — the  subject  is  afraid  to  cross  an 
open  square,  hugs  to  railings  and  keeps  close  to  the  houses. 
Claustrophobia,  fear  of  close  spaces,  crowded  rooms.  Astra- 
phobia,  fear  of  thunder  and  lightning.  Acrophobia,  fear  of 
being  in  high  places,  etc. 

These  phobias  come  on  suddenly,  overwhelm  the  patient,  who 
is  seized  with  trembling,  pallor,  sweating  and  all  the  signs  of 
fear,  despite  the  fact  that  he  appreciates  fully  meantime  that 


2l8  OUTLINES    OF    PSYCHIATRY. 

there  is  no  reason  for  fear  and  has  a  full  understanding  of  the 
morbid  character  of  his  obsessions. 

The  morbid  desires  are  in  the  main  the  desires  for  liquor 
and  drugs.  In  dipsomania  the  patient  has  periodical  attacks  of 
discomfort  often,  with  feeling  of  pressure  on  the  head  and 
tachycardia;  this  continues  to  grow  worse  until  the  desire  to 
take  liquor  is  yielded  to.  We  have  somewhat  similar  condi- 
tions with  desire  for  morphine,  cocaine,  etc. 

Impulsive  obsessions  include  the  various  mmiias.  Some  of 
the  more  common  manias  are  kleptomania — impulse  to  steal, 
the  patient  often  taking  what  is  not  wanted  and  what  he  could 
afford  to  buy.  Pyromania,  an  impulse  to  set  fire  to  things. 
Arithmomania,  the  impulse  to  count  everything,  the  letters  in 
a  word,  objects  passed  in  the  street,  etc.  Onomatomania,  the 
obsession  of  a  word,  usually  the  impulse  to  repeat  it  over  and 
over  again,  or  to  seek  for  it  in  one's  memory,  etc. 

These  manias,  as  in  dipsomania,  make  the  patient  uncomfor- 
table until  yielded  to;  although  he  appreciates  the  abnormal 
character  of  the  obsession,  the  tendency  has  finally  to  be 
yielded  to. 

Intellectual  obsessions  are  the  obsessions  which  do  not  lead 
to  action  and  which  have  not  a  large  emotional  content.  Here 
would  be  included  the  doubters,  who  are  always  asking  them- 
selves questions  about  trivial  things,  though  often  in  regard  to 
religious  matters,  wondering  if  there  is  a  God  and  the  like. 
The  so-called  metaphysicians  especially  are  occupied  with  ab- 
stract questions  on  the  nature  of  the  universe,  problems  of 
matter  and  mind  and  the  like. 

Regis  makes  a  class  of  abonlic  obsessions  which  lead  to  inhi- 
bition of  all  action,  producing  such  symptoms  as  astasia-abasia 
— inability  to  stand  and  walk.  This  symptom,  however,  is 
usually  hysterical. 

The  peculiarity  of  all  psychasthenic  symptoms  is  that  they 
occur  with  clear  consciousness,  the  patient  fully  recognizing 
their  abnormal  nature. 

Course  and  Prognosis. — The  course  of  psychasthenia  is  epi- 


BORDERLAND   AND    EPISODIC    STATES.  2ig 

sodic  and  the  outlook  in  the  main  not  very  good  as  to  recovery, 
as  there  is  usually  a  pronounced  neuropathic  basis  for  the 
symptoms. 

Treatment. — The  treatment  should  be  directed  to  improving 
the  general  health,  but  the  main  line  of  treatment  is  mental  and 
requires  the  most  detailed  regulation  and  re-education  of  the 
mental  life. 

Psychopathic  Constitution. — There  are  many  anomalies  of 
character  which  because  normal  or  usual  to  the  individual  can- 
not be  said  to  properly  constitute  insanity,  but  because  they 
lead  to  a  rather  inefficient  type  of  adjustment  of  the  individual 
to  the  environment,  and  because  persons  exhibiting  these  pecu- 
liarities often  become  actively  insane,  may  be  considered  as 
borderland  conditions. 

We  have  already,  in  previous  chapters,  learned  something  of 
the  hysteric  and  epileptic  characters.  We  know  the  general 
type  of  inefficiency  of  the  neurasthenic  and  latterly  have  de- 
scribed the  psyclmsthcnic  character,  and  attention  has  been 
called  to  the  unresistive  and  the  post-traumatic  types  with  the 
intolerance  of  alcohol  and  fever. 

Besides  these  there  are  the  "cranks,"  who,  with  some  pet 
scheme,  closely  approach  the  paranoiac  type  and  that  host  of 
ill-balanced,  eccentric  individuals  who  may  be  superficially  bril- 
liant but  lack  continuity  of  purpose  and  capacity  for  the  con- 
tinuous expenditure  of  effort  in  any  one  direction.  Their  life, 
to  use  the  well  chosen  words  of  Regis,  is  one  "  long  contradic- 
tion between  the  apparent  wealth  of  means  and  poverty  of 
results." 

Constitutional  anomalies  of  mood  are  seen,  those  who  are 
always  depressed  for  no  particular  reason — psychopathic  de- 
pression— and  the  opposite  state — psychopathic  exaltation. 
Other  cases  never  seem  to  be  quite  able  to  successfully  cope 
with  conditions;  they  are  the  failures  of  life,  the  cases  of  con- 
stitutional inferiority. 

More  pronounced  defects  of  character  are  seen  in  the  crimi- 


220  OUTLINES    OF    PSYCHIATRY, 

nal  classes,  many  of  whom  lack  the  ordinary  moral  inhibitions 
and  are  properly  classed  as  moral  imbeciles. 

Anomalies  of  the  Sexual  Instinct. 

Quantitative  Anomalies. — These  are  frigidity  or  lack  of 
desire  for  sexual  congress — sexual  ancesthesia — or  erotocism — 
sexual  hypercethesia. 

Qualitative  Anomalies. — These  are  inversions  and  perver- 
sions. Inversion  consists  of  a  lack  of  harmony  between  the 
physical  and  the  psychical  sex  and  leads  to  homosexuality  or 
desire  for  persons  of  the  same  sex.  Various  physical  anoma- 
lies are  found  in  these  persons.  For  example,  the  general  con- 
formation of  the  body,  pilosity,  etc.,  may  indicate  one  sex, 
while  the  genitalia  are  of  the  other.  The  perversions  are  many 
and  include  the  various  abnormal  means  of  gratifying  the 
sexual  appetite.     The  most  important  are: 

Masturbation. — Masturbation  is  very  frequent  among  psy- 
chopathies and  much  oftener  a  result  than  a  cause  of  mental 
anomalies  though  undoubtedly  an  important  factor  in  some 
cases  of  acute  psychosis. 

Active  Algolagnia  (Sadism).  —  The  gratification  of  the 
sexual  feeling  by  the  infliction  or  sight  of  pain — real  or  simu- 
lated— in  the  latter  case  the  sadism  is  symbolic.  As  the  male 
is  normally  the  more  active  and  aggressive  in  the  sexual  rela- 
tion we  find,  as  might  be  expected,  this  anomaly  more  fre- 
quently in  men. 

Passive  Algolagnia  (Masochism) . — The  gratification  of  the 
sexual  feeling  by  suffering  pain — real  or  simulated.  In  the 
latter  case  it  is  symbolic.  The  female,  being  the  more  passive 
of  the  two  sexes  in  the  sexual  relation,  so  we  find  an  exaggera- 
tion of  this  passivity  more  common  among  women. 

Fetichism. — Sexual  excitement  and  gratification  by  the  sight, 
contact  or  possession  of  some  object  or  part  of  the  body.  The 
object  is  usually  some  wearing  apparel,  such  as  shoes,  handker- 
chief, petticoat  or  a  part  of  the  body  other  than  the  sexual 
organs. 


BORDERLAND   AND    EPISODIC    STATES.  221 

Bestiality. — Sexual  relation  with  animals. 

Exhibitionism. — Sexual  gratification  by  exposing  the  genital 
organs. 

Nechrophilia. — The  desire  to  have  sexual  congress  with  a 
dead  body. 


CHAPTER   XVIII. 
IDIOCY  AND  IMBECILITY. 

In  drawing  a  distinction  between  dementia  and  idiocy, 
Esquirol  well  said :  "  The  demented  man  is  deprived  of  the 
good  that  he  formerly  enjoyed;  he  is  a  rich  man  become  poor; 
the  idiot  has  always  lived  in  misfortune  and  poverty."  The 
idiot,  the  imbecile,  the  feeble-minded  lack  something;  the  insane 
are  suffering  from  a  disorder  of  that  which  they  possess. 

The  distinction  is  here  clearly  drawn  between  insanity  and 
idiocy  and  imbecility.  The  former  is  a  breaking  down,  a  dis- 
order of  mind,  the  other  is  the  result  of  a  certain  lack  of  mind. 
In  making  this  distinction  we  must  not  lose  sight  of  the  fact 
that  the  feeble-minded,  imbecile  and  idiot  may  become  insane, 
and  transient  attacks  of  mental  disturbance  of  this  sort  are 
not  infrequently  observed  among  them. 

The  various  grades  of  idiocy  and  imbecility  may  take  their 
origin  at  any  point  in  the  development  of  the  individual,  during 
intra-uterine  life,  at  birth  as  a  result  of  injury,  after  birth  as 
a  result  of  injury  or  disease  which  interferes  with  further 
development. 

Thus  various  defect  conditions  fall  rather  naturally  into  cer- 
tain groups,  but  the  same  difficulty  is  experienced  in  endeavor- 
ing to  classify  them  from  any  one  standpoint,  as  was  expe- 
rienced in  the  realm  of  the  psychoses.  They  will  be  consid- 
ered under  the  several  practical  heads  and  a  few  words  devoted 
to  each  class. 

Feehle-mindedness. — A  condition  of  slight  mental  defective- 
ness capable  of  much  improvement  by  educational  methods. 
The  afflicted  individual  may  ultimately  take  a  place  in  the 
world  and  be  self-supporting  under  favorable  circumstances. 

Imbecility. — A  condition   of  mental  deficiency  which  can, 


IDIOCY    AND    IMBECILITY.  22$ 

however,  be  materially  improved  by  training,  but  not  suffi- 
ciently for  the  subject  to  take  a  place  in  the  world. 

Moral  Imhecility  is  a  condition  of  mental  defectiveness 
which  is  shown  in  the  absence  of  the  highest  functions,  particu- 
larly the  moral;  capable  of  training  to  a  considerable  degree, 
but  always  a  menace  to  society. 

Idio-Imhecility  is  a  condition  midway  between  idiocy  and 
imbecility. 

Idiocy  is  a  condition  of  profound  mental  defectiveness.  The 
lower  grades  are  unteachable,  while  the  higher  may  be  trained 
slightly  in  self-help,  i.  e.,  to  attend  to  the  calls  of  nature. 

Causes. — The  causes  of  idiocy,  like  those  of  insanity,  are 
numerous  and  varied.  Hereditary  defects  are  found  in  the 
ascendants  in  a  large  proportion  of  cases.  Accidents  and  in- 
juries, especially  those  associated  with  prolonged  labor  and 
instrumental  delivery,  are  common  causes,  while  diseases  in- 
volving the  brain,  such  as  the  acute  infections — pneumonia, 
typhoid,  the  exanthemata — and  syphilis  often  play  a  role. 
Alcoholism  in  one  or  both  parents,  especially  drunkenness  at 
the  time  of  conception,  is  probably  a  very  frequent  factor,  while 
any  infection  or  debilitating  condition  of  the  parents  is  impor- 
tant. Fright  of  the  mother  probably  is  a  potent  factor  as  indi- 
cated by  the  statistics  of  births  during  sieges. 

The  popular  idea  that  consanguineous  marriages  are  produc- 
tive of  idiocy  in  the  offspring  is  not  borne  out  by  statistics. 
Consanguineous  marriages  are  probably  no  more  dangerous 
than  any  others.  They  would  only  produce  unduly  direful 
results  when  a  bad  family  strain  is  present  in  both  parties  and 
is  thus  cumulative  in  the  offspring. 

General  Considerations. — The  symptoms  which  should  at- 
tract attention  to  the  mental  state  of  a  child,  aside  from  marked 
physical  abnormalities,  are  a  stupid  and  vacant  look,  prolonged 
and  unprovoked  crying  and  difficulty  in  taking  the  breast. 

Later  on  it  is  noticeable  that  the  several  faculties  do  not 
develop  when  they  should.  The  child  neither  learns  to  walk 
or  to  talk  as  early  as  other  children,  and  a  study  of  other  psychic 


2  24  OUTLINES    OF    PSYCHIATRY. 

qualities  would  develop  the  same  fact.  The  degree  of  idiocy 
may  be  measured  by  the  stage  of  development  reached  as  com- 
pared with  the  average  normal  child.  For  such  detailed  com- 
parisons the  student  is  referred  to  special  w^orks. 

The  idiot  is  usually  comparatively  quiet  or  very  excitable 
and  has  been  correspondingly  classified  as  apathetic  or  excit- 
able. Certain  of  the  excitable  idiots  keep  up  certain  definite 
and  characteristic  movements  almost  continuously — these  are 
the  rhythmic  idiots.  Many  other  motor  anomalies  are  found 
frequently,  such  as  paralysis,  athetosis  and  epilepsy. 

Amaurotic  Family  Idiocy. — This  form  of  idiocy,  described 
by  Sachs,  seems  to  occur  almost  exclusively  among  Jewish 
children.  The  principal  symptoms  are  idiocy,  paralysis, 
usually  spastic,  of  all  four  extremities  and  progressive  blind- 
ness from  optic  nerve  atrophy.  The  patients  usually  die 
during  infancy. 

Thyroigenous  Idiocy. — This  form  includes  idiocy  due  to 
endemic  and  sporadic  cretinism  and  also  cases  due  to  myxe- 
dema. They  present  the  characteristic  symptoms  of  these  dis- 
eases with  those  of  idiocy. 

Hydrocephalic  Idiocy.  —  Idiocy  associated  w-ith  hydro- 
cephaly. Although  hydrocephalus  usually  leads  to  early  death, 
life  may  be  prolonged  to  an  advanced  age  and  marked  degrees 
of  the  malady  may  occur  without  the  profound  defects  of  idiocy. 
A  case  of  most  pronounced  hydrocephalus  recently  died  in  the 
hospital  upwards  of  fifty  years  of  age.  During  his  earlier  life 
he  had  made  a  livelihood  by  the  simple  process  of  ringing  a 
church  bell.  During  the  latter  months  of  his  life  he  deterior- 
ated very  profoundly,  became  absolutely  blind  and  deaf,  unable 
to  lift  his  tremendous  head  from  the  pillow-  and  died  in  coma. 
All  of  the  symptoms  were  undoubtedly  due  to  the  pressure,  as 
the  brain  was  found  post-mortem  to  be  little  else  than  a  bag 
of  water. 

Microcephalic  Idiocy.  —  Idiocy  associated  with  extreme 
smallness  of  head.  No  definite  rule  can  of  course  be  laid  down 
as  to  the  definite  size  of  head  that  shall  be  considered  as  micro- 


IDIOCY   AND   IMBECILITY.  225 

cephalic,  but  Ireland  says  in  general  that  all  heads  below  seven- 
teen inches  in  circumference  (431  millimeters)  may  be  so 
considered. 

Paralytic  Idiocy. — Idiocy  associated  with  paralysis.  The 
commoner  paralyses  are  the  monoplegias  and  diplegias.  These 
conditions  are  consequent  upon  gross  cerebral  lesions,  such  as 
the  lack  of  cerebral  substance,  resulting  in  a  cyst  connected 
with  the  ventricle — true  porencephalus,  or  due  to  cysts  not  con- 
necting with  the  ventricles  and  resulting  from  softening,  hem- 
orrhage or  inflammation — faJse  porenceplialus.  It  depends 
entirely  upon  the  location  of  the  lesions  as  to  the  symptoms. 

Epileptic  Idiocy. — Idiocy  with  epilepsy.  Epilepsy  is  a  com- 
mon associate  of  idiocy,  especially  in  those  cases  where  there 
are  gross  cerebral  lesions  as  in  the  paralytic  idiots.  The  term 
epileptic  idiocy  should  be  reserved  for  those  cases  where  the 
idiocy  may  reasonably  be  supposed  to  depend  on  the  epilepsy. 

Traumatic  Idiocy, — Idiocy  the  result  of  trauma.  The 
most  common  trauma  are  those  associated  with  prolonged  and 
difficult  labor  with  instrumental  delivery. 

Sensorial  Idiocy. — Idiocy  by  deprivation.  This  is  the 
idiocy  that  results  when  a  child  is  deprived  of  two  or  more  of 
the  principal  senses,  such  as  sight  and  hearing.  As  knowledge 
and  education  are  dependent  in  the  first  instance  upon  the  integ- 
rity of  the  sensorium,  such  a  serious  defect,  making  it  impos- 
sible for  the  child  to  receive  the  material  out  of  which  knowl- 
edge is  elaborated,  results  in  lack  of  development  of  the  mind. 

Inflammatory  Idiocy. — Here  we  find  idiocy  due  to  the 
various  forms  of  inflammatory  conditions  of  the  brain  and 
meninges.  The  cause  of  these  inflammations  may  be  any  of 
the  infectious  fevers,  as  pneumonia,  typhoid,  the  exanthemata. 
The  inflammation  may  be  meningitic  or  include  the  brain 
proper,  as  in  Striimpell's  infantile  encephalitis  of  the  motor 
region  analogous  to  anterior  poliomyelitis.  The  physical 
symptoms  vary  according  to  the  location  and  the  extent  of 
destruction  of  tissue  resulting, 
16 


226  OUTLINES    OF    PSYCHIATRY. 

Sclerotic  Idiocy. — Idiocy  found  not  infrequently  associated 
with  the  condition  known  as  tuberous  sclerosis.  These  cases 
usually  die  young,  being  greatly  reduced  by  frequent  epileptic 
attacks.  The  post-mortem  discloses  numerous  areas  of  firm 
consistence  and  white  color  in  which  the  nervous  elements  are 
lacking.     The  cause  of  the  condition  is  not  fully  determined. 

Idiots-Savants. — These  are  rare  cases  who,  although  idiots, 
still  have  some  special  faculty  wonderfully  developed.  It  may 
be  music,  calculation,  memory  for  some  certain  variety  of 
facts,  etc. 

The  calculators  can  name  the  answer  to  mathematical  prob- 
lems almost  instantly ;  the  musical  prodigies  often  play  well  and 
even  improvise ;  one  of  my  cases  could  instantly  name  the  day 
of  the  week  for  any  date  for  years  back.  Many  of  these  cases 
have  a  capacity  for  mimicry  and  buffoonery,  and  from  this  class 
undoubtedly  were  recruited,  in  the  old  days,  many  of  the  court 
fools. 

The  psychology  of  these  cases  is  not  understood.  The  pa- 
tients themselves  are  quite  unable  to  give  an  explanation  of 
their  abilities. 

Idiots  are  further  spoken  of  by  general  descriptive  terms  that 
indicate  the  resemblance  to  certain  types.  Thus  we  have  the 
Mongolian,  American  Indian  and  Negroid  types. 

Course  and  Prognosis. — The  condition  of  these  defectives 
usually  remains  stationary,  though  sometimes  severe  epilepsy 
or  severe  illness  may  reduce  them  still  further.  Some  may 
actually  become  insane,  developing  hallucinations,  abnormal 
activities,  and,  if  the  mentality  permits,  delusions.  The  prog- 
nosis is  absolutely  bad  as  to  recovery  and  poor  even  as  to 
life,  the  mortality  of  idiots  being  far  above  that  of  the  general 
population. 

Treatment. — Aside  from  the  thyroid  treatment  in  the  cre- 
tinous forms  the  sole  treatment  is  educational.  This  can,  of 
course,  only  develop  what  is  already  there  and  in  the  main 
should  be  practical  only,  teaching  the  child  to  care  for  itself. 
The  most  is  to  hoped  for  in  the  sensory  types,  where  there  may 


IDIOCY    AND   IMBECILITY.  22/ 

be  no  real  defect  of  brain,  only  an  absence  of  sense  organs. 
The  well-known  cases  of  Laura  Bridgman  and  Helen  Kellar 
illustrate  the  wonderful  results  that  may  be  accomplished  in 
this  class  of  cases.  To  get  results  at  all  requires  in  the  highest 
degree  patience,  tireless  application  and  ingenuity,  qualities  few 
persons  possess. 


INDEX 


Actions,  4 
Affects,  6 
Alcoholic  epilepsy,  195 

hallucinosis,   195 
Alcoholism,   189 
chronic,    193 
course,   198 
pathology,  199 
treatment,   199 
Allopsychoses,  49 
Amnesia,  61 
Anger,  61 
Anxiety,  165 

Apoplectiform  seizures,   133 
Apoplexy,  21  r 
Apperception,  tests  for,  82 
Apprehension,  tests  for,  82 
Aprosexia,  62 

Argyll-Robertson  pupil,  127 
Arterio-sclerosis,  211 
Association,  clang,  54 

tests  of,  90 
Attention,  disorders  of,  62 
tests   of,   86 
voluntary,   144 
Automatism,  60,  154 
Autopsychoses,  49 
Auto-toxic  psychoses,   187 

Baths,    continuous,    29 
Bestiality,  221 

Catalepsy,  60,  153 

Catatonia,  152 

Catatonic  excitement,  154 

stupor,   152 
Causes  of  insanity,  21 
Character,  paranoiac,  96 

study  of,  19 
Chloral,  32 
Chloralamid,   32 


Chorea,   210 
Circumstantiality,  56 
Clang  association,  54 

in   mania,    115 
Classification  of   insanity,   20 

of  causes  of  insanity,  21 
Cocainism,  203 
Compulsions,  58 
Concepts,  classification  of,  49 

imperative,    53 
Conduct,  definition  of,  5 
Confabulation,   197 
Confusion,    166 

acute  hallucinatory,  185 
definition  of,    181 
primary,  186 
secondary,  186 

in  mania,  117 
senile,  174,  175 
Consciousness,  clouding  of,  44 
threshold   of,   44 
wave  of,  46 
double,  64 
Constitutional  inferiority,  219 
Cranks,  219 
Cretinism,  188 

Decortication,  136 
Definition  of  insanity,  14 
Degenerates,  insanity  of,   105 
Degeneration,  stigmata  of,  IDS 
Delirium,  collapse,  184 

definition  of,  181 

febrile,  192 

infection,   182 

of  negation,  64 

occupation,   192 

senile,  176 

sine  delirio,   192 

tremens,  190 
Delusional  control,  165 


228 


INDEX 


Delusions,  47 

changeable,  48 

of  explanation,  99,  168 

fixed,  48 

of  grandeur,  168 

hypochondriacal,  167,  168 

nihilistic,  167 

of  persecution,  98,  168 

of  possession,  168 

of  poverty,  168 

of  reference,  100 

of  relativity,  98 

of  sin,  164,  167 

systematized,  49 

unsystematized,  48 
Dementia,  alcoholic,  198 
Dementia  precox,  142 

general  characteristics,   142 

etiology,  142 

general    symptomatology,    143 
mental,  143 
physical,  147 

varieties,   147 

heboidophrenia,   147 
hebephrenia,   148 
catatonia,  152 
paranoid,  157 
mixed  states,  161 

course,  161 

prognosis,  161 

diagnosis,  161 

pathology,  162 

treatment,   162 
Depersonalization,  64 
Depression,  61 

apprehensive,   164 

symptomatic,  163 
Deterioration,  senile,  175 
Diabetes,  187 
Dipsomania,  198 
Disorientation,  47 
Distractibility,  55 

in  mania,  114 
Dotard,    173 
Dream  states,  46 

alcoholic,  197 

epileptic,  209 


Dream,  hysterical,  205 
Drunkenness,  189 
pathological,  190 


> 

/ 


229 


Echolalia,  60,  154 
Echopraxia,  60,  154 
Emotion,   definition   of,  6 

disorders  of,  60 
Emotional  depression  in  paranoia,  98 

deterioration   in   dementia  pre- 
cox, 145 

exaltation  in  mania,  116 
Epilepsy,  209 

alcoholic,   195 
Epileptiform  seizures  in  paresis,  132 
Epochal  insanities,  179 
Exaltation,  60 
Examination,   special,  73 

physical,  73 

neurological,   T^ 

mental,  74 
Exhaustion  psychoses,  184 
Exhibitionism,  221 
Exophthalmic  goitre,  188 

Febrile  psychoses,   182,   183 
Feeble-mindedness,  222 
Feeling  of  unreality,  64,  167 
Feelings,  6 
Fetichism,  220 
Flexibilitas  cerea,  60,   153 
Flight  of  ideas,  54 

sensory,   193 
Food,  refusal  of,  30 

Goal  idea,  54 
Grimaces,   153 

Hallucinations,  35 
apperception,  36 
auditory,    39 

in  paranoia,  99 
in   depression,   119 
haptic,  40 
hypnagogic,  37 
in  mania,  115 
motor,  41 


230 


INDEX 


Hallucinations,  organic,  40 

pseudo,  36 

psychic,  36 

reflex,  41 

of  smell,  40 

of  taste,  40 

visual,  40 
Heredity,  22 

dissimilar,  24 

similar,   24 
History  of  family,  66 

of  illness,  70 

of  patient,  68 
Hydrotherapy,  29 
Hyoscyamus,  33 
HjT)ennnesia,  61 
Hyperprosexia,  62 
Hypochondriacal    ideas    in    depres- 
sion, 118 

in  paranoia,  98 

in  paresis,  135 
Hysteria,  205 

Ideas,  autochthonous,  53 

definition  of,  4 

fixed,  51 

flight  of,  54 

goal,  54 

of  grandeur,   167 

hyperquantivalent,  50 

imperative,  53 

of  insignificance,  167 

leveling  of  in  mania,  115 

poverty  of,   150 

of  self-importance  in  paranoia, 
100 

of   unworthiness,    167 
Idiocy  and  imbecility,  222 

causes,  223 

general  considerations,  223 

course,  226 

prognosis,  226 

treatment,  226 
Idiocy,  amaurotic  family,  224 

epileptic,  225 

hydrocephalic,  224 

inflammatory,  225 


Idiocy,  microcephalic,  224 

paralytic,  225 

sclerotic,  226 

sensorial,  225 

thyroigenous,  224 

traumatic,  225 
Idio-imbecilit}',  223 
Idiots,  apathetic,  224 

excitable,  224 

rhythmic,  224 
Illusions,  35 
Imbecility,  222 

moral,   223 
Impulsions,   57 
Impulsive  acts,   156 
Infection-exhaustion  psychoses,  181 

diagnosis,   185 

treatment,  186 
Insanity,  causes  of,  21 

classification,  20 

definition,    14 

of  degenerates,  105 

treatment  of,  29 

as  type  of  reaction,  14 
Insomnia,   treatment  of,   32 
Intellect,  2 
Involution  melancholia,   163 

general  considerations,  163 
characterization,  163 

etiology,  163 

symptomatology,   164 

melancholia  vera,  166 
anxietas  prasenilis,  166 
depressio  apathetica,  167 

course,  168 

prognosis,  168 

termination,   168 

pathology,   168 

treatment,  169 

differential  diagnosis,   169 

Judgment,  definition   of,  4 

weakness  of  in  paranoia,  102 

Korsakow's  psychosis,  196 
syndrome  in  paresis,  135 
in  senility,  174 


INDEX 


Mania,  acute  delirious,  117 
Manias,  57 

Manic-depressive  psychoses,  108 
etiology,  108 

general  symptomatology,  109 
hypomania,    ill 
actue  mania,  114 
delirious  mania,  116 
simple  retardation,   117 
acute  melancholia,  118 
depressive  stupor,  119 
periodical  psychoses,  120 
maniacal  stupor,  121 
agitated  depression,  121 
unproductive  mania,  121 
course,   121 
prognosis,  121 
differential    diagnosis,    122 
pathology,   123 
treatment,  123 
Mannerisms,  58,  156 
Masochism,   220 
Masturbation,   220 
Melancholia,  affective,  118 
agitated,  165 
depressive,  118 
involution,  163 
Memory,  definition  of,  6 

in  dementia  precox,  144 
disorders  of,  61 
falsification  of,  62 
tests  of,  87 
Motorium,  2 
Multiple  sclerosis,  210 
Muscular  tension,  153 
Mutism,  153 
Myxoedema,  188 

Necrophilia,  221 
Negativism,  59 

in  dementia  precox,  152 
Neurasthenia,    208 
Nihilistic  delusions,  167 

ideas,  168 

Observation,  general,  72 
Obsessions,  52,  217 


/ 


231 


Obsessions,  emotional,  217 

impulsive,  218 

intellectual,  218  ^^ 

Opiumism,  200 

Paralexia,  193 
Paraldehyde,  32 
Paralysis  agitans,  210 
Paralytic  dementia,  130 

insanity,  130 
Paramnesia,  61 
Paranoia,  94 

general  characteristics,  94 
etiology,  94 

general   symptomatology,   94 
special  symptomatology,  97 
varieties,  102 

hallucinatoria,  103 
combinatoria,    103 
early  or  original,  103 
late  or  acquired,  103 
querulous  or  litigious,  103 
persecutory,  104 
expansive,   104 
inventive,  104 
reformatory,  104 
religious,  104 
erotic,  104 
secondary,   106 
acute,  106 
course,  105 
prognosis,  105 
differential  diagnosis,  105 
pathology,  105 
treatment,  105 
Paranoid  states,  106 
Paraphasia,  193 
Paresis,  124 

etiology,  124 

general  characteristics,  124 
general  considerations,  125 
tabetic  form,  132 
galloping  form,   134 
demented  form,  134 
excited  form,  134 
agitated  form,  134 
depressed  form,  135 


232 


3,  pa^c 


INDEX 


Paresis,  pa*iology,  136 

differential  diagnosis,  137 

oa^^e,   140 

prognosis,   140 

treatment,   140 
Paretic  seizures,  132 
Perception,  2 

definition  of,  4 

disorders  of,  35 
Perseveration,  59 
Personality  in  depression,  119 

disorders  of,  63 

multiple,  64 

transformation   of,   63,   loi 
Phobias,   52 
Plasma  cells,  137 
PoljTieuritis,  210 
Post-febrile  psychoses,  182,  183 
Pre-febrile  psychoses,  182 
Pressure  of  activity,  116 
Pseudo-paranoia,  alcoholic,   196 
Pseudo-paresis,  alcoholic,  194 
Pseudo-stupor,  60 
Psychasthenia,  216 
Psychomotor  activity,  57 
Psychopathic  constitution,  219 

Reasoning,  4 
Reflex,  light,  1^7 

consensual,  128 

sympathetic,  128 
Retardation,  56 
Retrospective  delusions,  loi 

falsification  of  memory,  ici 

Sadism,  220 
Schnautzkrampf,   153 
Seizures,  paretic,  132 
Senile  confusion,  174,  175 

delirium,  176 

det'-'Horation,   175 
Senile  psychoses,  171 

causes,  171 

symptomatology,  171 


Senile  psychoses,  course  and  prog- 
nosis, 176 

diagnosis,    177 

pathology,   177 

treatment,  178 
Sensation,  definition  of,  3 
Sensorium,  2 

Sentiments,  definition  of,  6 
Sexual  perversion,  220 
Somatopsychoses,  49 
Speech,  tests  of,  81 
St^.bchenzellen,  137 
Stereotypj-,  58 
Stupor,  catatonic,  152 

depressive,  119 
Suggestibility,  60,  154 
Sulfonal,  32 
Syphilis,  211 

Thinking,  2 

definition  of,  4 

difficulty  of,  56 

tests  of,  91 
Thought,  content  of,   145 

dilapidation  of,  145 

looseness  of  train  of,  149 

paralysis  of,  57 
Thyroigenous  psychoses,  188 
Toxic  psychoses,  189 
Traumatism,  213 
Treatment  of  insanity,  29 
Trional,  32 
Tumor,  210 

Uremia,    187 

Verbigeration,  59,  154 
Volition,    2 

definition  of,  5 

disorders  of,  57 

Wahnsinn,  106 
Word  salad,  147 
Wet  brain,  199 


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